LIBRARY OF CONGRESS. 






UNITED STATES OP AMERICA.! 



LECTURE S 



ORTHOPEDIC SURGERY 



DISEASES OF THE JOINTS. 



DELIVERED AT BELLEVUE HOSPITAL MEDICAL COLLEGE, 
DURING THE WINTER SESSION OF 1874-1875. 



BY 

LEWIS A. SAYKE, M. D., 

Professor of Orthopedic Surgery, Fractures and Dislocations, and Clinical Surgery, in Bellerue Hos- 
pital Medical College; Surgeon to Bellevue Hospital; Consulting Surgeon to Charity Hospital; 
Consulting Surgeon to St. Elizabeth's Hospital; Consulting Surgeon to Northwestern 
Dispensary; Member of the American Medical Association; Permanent Member of 
the New York State Medical Society ; Fellow of the New York Academy 
of Medicine ; Member of the New York County Medical Society, of 
the New York Pathological Society, of the Society of Neurology, 
of the Medico-Legal Society ; Honorary Member of the 
New Brunswick Medical Society; Honorary Mem- 
• ber of the Medical Society of Norway ; Knight 
of the Order of Wasa, by His Majesty 
the King of Sweden, etc., etc. 



ILLUSTRATED BY 274 WOOD-EXGRAYIFGS. 



NEW YORK: 
D. APPLETON AND COMPANY, 

549 AND 551 BROADWAY. 

1876. 




Entered, according 1 to Act of Congress, in the year 1876, by 
D. APPLETON & COMPANY, 

In the Office of the Librarian of Congress, at Washington. 



DEDICATION. 



To the Physicians and Students who have so attentively lis- 
tened to my lectures, and who have sustained and encouraged 
me in the enunciation of new truths by their devotion and friend- 
ship, this work, which I hope may enable them to remember and 
practically apply the principles therein taught, is humbly in- 
scribed by their sincere friend, 

THE AUTHOR, 

January 1, 1876. 



PEEFA OE. 



Foe some years past I have been in the frequent receipt of 
letters from medical gentlemen of the highest standing, in dif- 
ferent sections of our country, as well as from many abroad, 
urging me to prepare a work on Orthopedic Surgery and Dis- 
eases of the Joints setting forth my peculiar views of their 
pathology and method of treatment. 

As many of my views were so directly at variance with the 
standard authorities, I hesitated to write until a larger experi- 
ence should either confirm my observations or prove them to 
be erroneous. In the latter case, of course, I should have no 
occasion for publishing. 

A more extended experience has confirmed my original 
views ; but constant professional occupation has prevented me 
from complying with the request of my friends, as I have been 
unable to find the time to perform the manual labor of writing 
such a work as I should desire to produce. 

I therefore employed Dr. Wesley M. Carpenter, so well 
known to the profession in this city for his accuracy as a steno- 
graphic reporter, to follow me during the course of last win- 
ter's lectures, at the Bellevue Hospital Medical College, and 
the present work is the result. Upon its perusal in the proof, 
I find many expressions which I would like to change, but, as 



vi PEEFACE. 

these lectures were delivered extemporaneously and without 
preparation (many of them being clinical, and upon cases just 
presented to me for the first time in the lecture-room), I find 
it difficult to alter the text without destroying its originality. 

I therefore leave the work in its original form, making no 
claims for literary elegance, but simply desiring to tell what I 
think to be true, in such a manner as not to be misunderstood. 

I a addition to the cases brought before the class at this 
term, I have added others from my note-book and from the 
hospital records, to illustrate the principles taught. I have 
also added a few cases that I have before presented to the 
profession in medical journals, or at the different Medical Soci- 
eties, but, as they are typical illustrations of the principles I 
wished to teach, I have deemed them worthy of more perma- 
nent record. 

The long delay in getting the work through the press is on 
account of the number of illustrations, which have all been en- 
graved by Mr. E. S. Bross, of Nos. 14 and 16 Ann Street, from 
original drawings by Dr. L. M. Yale and from photographs; 
and I wish here to express my thanks for the very able man- 
ner in which he has performed the work. 

The illustrations of the instruments were all kindly fur- 
nished by Mr. John Eeynders, of 309 Fourth Avenue. 

I wish particularly to return my warmest thanks to Drs. 
Yale and Carpenter, and to Dr. ¥m. A. G-eorge, for most valu- 
able services in correcting proof, and other assistance wdiile 
the work was going through the press. 

LEWIS A. SAYEE. 

285 Fifth Atenue, January 1, 18*76. 



CONTENTS 



LECTURE I. 

INTRODUCTOR Y. 

History of Orthopedy. — General Considerations which should induce the Student 
to make it a Subject of Special Study. — General Plan of Instruction . page 

LECTURE II. 

DEFORMITIES. 

Definition. — Special Divisions and Definitions. — Etiology 



LECTURE III. 

DEFORMITIES. 

Etiology (continued). — Prognosis. — Diagnosis 13 

LECTURE IV. 

DEFORMITIES. 

Treatment. — General Principles of Operative Treatment. — Tenotomy. — Myot- 
omy. — Tenotomes. — Breaking up of Bony or Fibrous Anchylosis. — An- 
aesthetics . .. . .. . . . . . . . . .25 

LECTURE V. 

DEFORMITIES. 

Treatment (continued).— Mechanical Appliances.— General Principles governing 
their Use. — Elastic Tension. — Adhesive Plaster. — Electricity. — Instrument 
for testing Muscular Tissue. — Cases 30 

LECTURE VI. 

DEFORMITIES. 

Treatment (continued).— Manipulation.— Massage.— Dry Heat.— Baths.— Inunc- 
tion.— Gymnastics.— Medicinal Agents 41 

LECTURE VII. 

TALIPES. 

Definition. — Varieties and Combinations.— Mechanical Construction of the Nor- 
mal Human Foot.— Talipes Equinus.— Talipes Calcaneus.— Case of Division 
of Tendo-Achilles by an Accident. — Mechanical Treatment of Talipes Cal- 
caneus . 4Y 



viii CONTENTS. 

LECTURE VIII. 

TALIPES. 

Talipes Varus. — Causes of. — Case. — Complications. — Case.— Talipes Valgus. — 

Causes of. — Paralytic Variety, with Cases. — Treatment of the same . page 57 

LECTURE IX. 

TALIPES. 

Talipes Plantaris. — Causes of Talipes. — Treatment.— Indications for. — When to 
begin. — How to effect a Cure without Tenotomy . 72 

LECTURE X. 

TALIPES. 

Treatment (continued). — Methods of Dressing. — Splints. — Adhesive Plaster. — 
Bar well's Apparatus. — The Author's Club-Foot Shoe. — Crosby's Substitute 
for the Shoe. — Neil's Apparatus. — Case. — Talipes Varo-Equinus . . .81 

LECTURE XL 

TALIPES. 

Treatment (continued). — Tenotomy. — Indications for same. — Dressing applied 

after the Operation. — After-Treatment 95 

LECTURE XII. 

Corns. — Bunions. — Ingrowing Toe-Nails. — Supernumerary Toes. — Displacement 

of Tendons. — Bow-Legs. — Genu- Valgum, or Knock-Knee .... 138 

LECTURE XIII. 

DISEASES OP THE JOINTS. — ANKLE-JOINT. 

Anatomy of the Ankle- Joint. — Pathology of. — Disease of. — Sj^mptoms. — Treat- 
ment . . . . . • • • • • • • • • 153 

LECTURE XIV. 

DISEASES OF THE JOINTS. — ANKLE-JOINT (CONTINUED). 

Treatment (continued).— Description of Instrument.— Mode of Application.— 

Cases.— Disease of the Tarso-Metatarsal Articulation.— Case . . .163 

LECTURE XV. 

DISEASES OP THE JOINTS. — KNEE-JOINT. 

Anatomy of.— Structures affected by Disease.— Synovitis.— Disease of Ligaments. 
—Extravasation of Blood into the Cancellated Lamellae of the Bone.— Causes. 
—Early Symptoms, and those developed as the Disease progresses.— Pain 
over the Attachment of the Coronary Ligaments .184 

LECTURE XVI. 

DISEASES OP THE JOINTS. — KNEE-JOINT (CONTINUED). 

Treatment of Disease of.— Early Treatment. — Treatment in the Advanced Stages 
of the So-called " White-Swelling."— Apparatus for making Extension.— 
Mode of Application 193 



CONTENTS. ix 

LECTURE XVII. 

DISEASES OF THE JOINTS.— KNEE-JOINT (CONTINUED). 

Treatment of Chronic Disease (continued).— Removal and Reapplication of the 
Instrument.— Passive Motion.— Protection of the Joint after the Splint has 
been removed.— Shall the Joint be permitted to anchylose?— If so, in what 
position ?— Cases.— Operative Interference in Extreme Cases . page 207 

LECTURE XVIII. 

DISEASES OF THE JOINTS.— KNEE-JOINT (CONCLUDED).— EXSECTION. 

Mode of performing the Operation of Exsection — Splints and Dressings used after 
the Operation.— Partial Exsection.—" Bryant on the Least Sacrifice of Parts 
as a Principle in Operative Surgery."— Differential Diagnosis.— Bursitis.— 

Necrosis of the Lower Extremity of the Femur 219 

» 
LECTURE XIX. 

DISEASES OF THE JOINTS. MORBUS COXARIUS. 

Anatomy of the Hip-Joint.— Pathology of Blip-Disease.— Etiology.— Symptoms of 

First Stage . 227 

LECTURE XX. 

DISEASES OF THE JOINTS. — MORBUS COXARIUS (CONTINUED). 

Symptoms (continued). — Symptoms of the Second Stage and their Explanation. — 
Case. — Symptoms of the Third Stage. — Discussion of the Question of Dislo- 
cation in this Stage 241 

LECTURE XXI. 

DISEASES OF THE JOINTS. — MORBUS COXARIUS (CONTINUED). 

Treatment. — Mechanical Apparatus, and how applied ..... 257 

LECTURE XXII. 

DISEASES OF THE JOINTS. — MORBUS COXARIUS (CONTINUED). 

Treatment (continued). — Treatment for the First Stage. — Treatment for the Sec- 
ond Stage. — Treatment for the Third Stage. — Case illustrating Treatment of 
Advanced Hip-Disease without Complete Exsection. — Indications for Exsec- 
tion 273 

LECTURE XXIII. 

DISEASES OF THE JOINTS. — MORBUS COXARIUS (CONCLUDED). 

Treatment (continued). — Exsection. — History of the Operation. — The Operation 
described. — Mode of dressing the Limb after the Operation has been per- 
formed. — After-Treatment. — Tables of Exsection appended . . . .285 

LECTURE XXIY. 

DISEASES OF THE JOINTS. — THE DISEASES WHICH SIMULATE HIP-DISEASE. 

Sacro-Iliac Disease. — Disease of the Knee. — Caries of the Ilium. — Caries of the 
Ischium. — Periostitis of Adjacent Parts. — Psoas Abscess with Pott's Disease. 
— Inguinal Abscess. — Inflammation of the Psoas Magnus and Iliacus Internus 



x CONTENTS. 

Muscles. — Congenital Malformation of the Pelvis, commonly known as " Con- 
genital Dislocation." — Paralysis of the Lower Extremities.— Injuries of the 
Hip, including Diastasis, Fractures, and Dislocations . . . page 327 

LECTURE XXV. 

DISEASES AND DEFORMITIES OP THE SPINE. — POTT'S DISEASE, OR ANGULAR CURVATURE. 

Definition. — Anatomy of the Spinal Column. — Etiology. — Pathology. — Symptoms. 
• — Method of examining the Case. — Treatment. — Mechanical Appliances. — 
Plaster-of-Paris Jacket . .360 

LECTURE XXVI. 

DEFORMITIES OF THE SPINE. — ROTARY-LATERAL CURVATURE. 

The Term Rotary-Lateral Curvature explained. — Pathology of the Deformity. — 
Class of Persons in whom it occurs, and how it is developed. — Additional 
Causes. — Special Cause when the Deformity is developed in the Dorsal Re- 
gion. — Symptoms. — Treatment '. . .386 

LECTURE XXVII. 

ANCHYLOSIS. 

Derivation and Use of the Word. — True and False Anchylosis. — Position of Limb 
when Anchylosis becomes a Necessity. — Mode of determining which Form of 
Anchylosis is present.— Br isement force. — Mode of dressing the Limb after the 
Operation. — Cases • . 399 

LECTURE XXVIII. 

ANCHYLOSIS (CONTINUED). 

Bony or True Anchylosis.— -Operation, when present at the Hip-Joint. — Cases. — 

Bony Anchylosis at the Knee-Joint. — At the Elbow-Joint. — Case . . . 423 

LECTURE XXIX. 

VARIOUS DEFORMITIES NOT DESCRIBED IN PREVIOUS LECTURES. 

Deformity accompanying Facial Paralysis. — Torticollis. — Diseases of the Wrist- 
Joint. — Causes. — Treatment. — Method of making Extension and Counter-Ex- 
tension at the Wrist-Joint. — Case. — Wrist-Drop.— Causes of the Paralysis 
that gives Rise to the Deformity. — Why it gives rise to this Peculiar De- 
formity. — Symptoms. — Treatment . 450 



OETHOPEDIC SUEGEET 



DISEASES OF THE JOINTS. 



LECTUEE I. 



INTEODUCTOET. 



History of Orthopedy. — General Considerations which should induce the Student to 
make it a Subject of Special Study. — General Plan of Instruction. 

Gentlemen : The Faculty of this college have intrusted me 
with the very important duty of instructing you upon the subject 
of deformities of the human frame, their cause, methods of cor- 
rection, and means of prevention. 

I propose to do this in a series of theoretical and clinical lect- 
ures. In the former I shall endeavor to render you familiar 
with the nature, causes, diagnosis, and general treatment of de- 
formities; and in the latter I shall place before you abundant 
clinical material, and offer you ample opportunities to realize and 
test the practical bearing and application of the abstract princi- 
ples which I shall endeavor to teach. 

In this combination you cannot fail to master the subject 
thoroughly, and to prepare yourselves efficiently for the per- 
formance of your future duty in this particular branch of your 
profession. 

Heretofore, our subject has not received that attention at the 
hands of medical teachers it so eminently deserved. Students 
met with few opportunities to study it, either in theory or prac- 
tice, and the profession at large was hardly prepared to take 
charge of deformities and treat them successfully. For this rea- 
1 



2 INTRODUCTORY. 

son they were left to mere mechanics or professional pretenders, 
who, if they could construct any sort of machine, professed to 
cure all kinds of deformities. 

Any one at all acquainted with the importance and magnitude 
of this branch of surgery will not for a moment question the 
propriety of treating it under a special head, and constituting it 
the sole object of a professorial chair. 

This school, I believe, was the first to establish a special pro- 
fessorship for orthopedic surgery ; and I am happy to see that 
our good example is being followed by other institutions, as such 
teaching must necessarily enhance the value of the instruction 
students will receive from their Alma Mater. 

The importance of studying the treatment of deformities was 
admitted by the ancients, for we have from Hippocrates himself, 
who has been styled the " Father of Medicine," a treatise " On 
Articulations," in which he taught the proper method of band- 
aging, in cases of the infantile deformity of club-foot, which even 
in this day might be employed with advantage ; for any theory 
of treatment founded upon correct ideas remains true forever. 
Celsus described the radical cure of hare-lip, and of various other 
congenital deformities, in a manner similar to that of the present 
day. As time went on, various persons attempted to ascertain 
the correct method of remedying deformities of the human frame. 
Empirics, and pretenders of all sorts, appeared from time to time, 
who professed to have discovered i{ the true secret," and as there 
has always existed, and still exists, in the human mind, a disposi- 
tion to admire the marvelous, and to be governed by decided 
assertion, without proper and careful investigation into facts, so 
men then became, as they now become, the dupes of the design- 
ing quack, who nourished and grew important through their 
weakness. 

This tendency of human nature has shown itself, however, 
quite as much in other branches of the medical art as in that of 
orthopedy. Nothing can check this but the proper education of 
the mind, whereby it is accustomed to examine and study into 
the truth of every proposition presented for its consideration. 

Pretenders and quacks invariably publish accounts of their 
wonderful cures, and the miracles they have performed, never 
laying down any laws or rules to aid another in performing 
the same cure in similar cases. And this, gentlemen, constitutes 



HISTORY OF ORTHOPEDY. 3 

one of the essential differences between an honorable physician 
and the quack. The one labors to disseminate and diffuse his 
knowledge for the benefit of his whole profession, in order that 
he may relieve as much of human suffering as is within his 
power ; the other endeavors to conceal the little knowledge he 
may possess for his own particular profit or gain. 

Prof. Andry, of Paris, is looked upon as the founder of or- 
thopedy, from the fact that he was the first who attempted to 
comprise all the deformities of the human frame under one head, 
and adopted this comprehensive appellation orthopedy , from opOos, 
straight, and iraihevco, I educate. He tried to find out their 
common causes, and establish general principles and indications 
for their efficient treatment ; and published his work, " L'Ortho- 
pedie, on l'Art de prevenir et de corriger dans les Enfans les 
Deformites du Corp," at Paris, in 1741. 

Andreas Yenel, of Switzerland, in 1780, established an insti- 
tution in which he treated deformities of the human frame — 
club-foot, spinal curvature, etc. 

In the year 17S9, Thilenius, a physician of Frankfort, de- 
scribed the division of a contracted tendo-Achillis. The opera- 
tion here first described by Thilenius was, in fact, performed by 
Lorenz, who performed the operation March 26, 1782 ; but, as 
Thilenius first described it, he has generally been thought the 
first to have performed it. Scarpa, in 1803, applied an apparatus 
for the relief of a distorted foot. Michaelis and Sartorius also 
divided contracted tendons. Dupuytren and Delpech also in- 
vestigated and labored in the same direction without, however, 
accomplishing all they desired. Stromeyer, in 1830, first per- 
formed subcutaneous tenotomy for the relief of club-foot, and 
established it as a principle in operative surgery. Possessed of 
great talent, ardor, and energy, he caused his new principle to 
be generally known, and many great cures have since been ef- 
fected by its application. 

The names of Bruckner, Camper, Wenzel, Palletta, Jackson, 
Sommering, Heine, and others, must not be • forgotten, as each 
one assisted to develop scientific knowledge and orthopedic sur- 
gery. Also, Dieffenbach, Langenbeck, and many others in Ger- 
many, accomplished much ; while in France we find those of 
Bonnet, Guerin, Marjolin, Major, Delpech, and Malgaigne, con- 
spicuous. 



4 INTRODUCTORY. 

In England, Dr. Little stands preeminent, having introduced 
orthopedy into tHat country. Having suffered himself from con- 
genital club-foot, he knew how to estimate the relief afforded ; 
and to his exertions and energy London owes the establishment 
of the Royal Orthopedic Hospital. Within the first ten years 
succeeding its establishment, twelve thousand patients were there 
treated, which alone is a proof of its necessity. Dr. Little's col- 
leagues, Tamplin, Lonsdale, Broadhurst and Adams, have also 
done good service in the cause of orthopedic surgery and science. 

In our own country orthopedy met with very serious obsta- 
cles, the profession at that time being seriously opposed to any 
innovation, and particularly to any subdivision of medical science 
into specialties. And many medical men of even great profes- 
sional attainments, unwilling or unable to take the tedious trouble 
of attending to serious cases of deformity, would recommend such 
cases to various instrument-makers in order to get rid of them ; 
and these, mere mechanics, sustained by such recommendation, 
soon began to assume the name and responsibilities of " doctor," 
and would undertake the treatment of deformities, instead of ad- 
hering to their legitimate business, which was the manufacture of 
such instrumental aids as an intelligent surgeon might devise. 

The injury thus inflicted on medical science and professional 
honor can only be properly appreciated by those who, like my- 
self, have had frequent opportunities to witness its disastrous 
results. 

Dr. David L. Rogers was the first to perform tenotomy in 
this country ; he divided the tendo-Achillis in 1834, assisted by 
my colleague, Prof. James R. Wood. 

Dr. Detmold, who is now a Professor of Orthopedic Surgery 
in the College of Physicians- and Surgeons in this city, a German 
himself, and who had enjoyed the advantages of Prof. Stromeyer's 
instruction in Germany, introduced among us subcutaneous myot- 
omy in 1837, three years subsequent to the introduction of tenot- 
omy by Dr. Rogers, and made zealous efforts to render us con- 
versant with its technicalities and therapeutic efficacy. 

Dr. Yalentine Mott, in his " Travels in the East and in Eu- 
rope," published in 1842, expressed himself in the highest terms 
of admiration of orthopedic art, as he had seen it in Paris. It is 
but just to this distinguished surgeon that I should quote from 
his narrative, above referred to, in order to show how immeasu- 



HISTORY OF ORTHOPEDY. 5 

rably he was in advance of the profession at that time. In fact, 
in his declining years, we here see abundant evidence that he was 
still entitled to the appellation of & pioneer. 

He says : " It was my happy lot, even at my advancing time 
of life, to have resided in this capital (Paris), and to have wit- 
nessed, also, the dawning, as well as the meridian splendor of an- 
other new and illustrious era in the healing art ; I refer to that 
beautiful and exact science, limitedly denominated orthopedic 
surgery. 

" This great improvement, both in mechanical and operative 
surgery, is destined to be to the human frame what vaccination 
is and has been to the human features. As the discovery of Jen- 
ner has rid the world of a loathsome pestilence, and banished 
from our sight those disfigurations which made the most lovely 
lineaments and complexions hideous to behold, so will orthopedic 
surgery, by its magic touch, unbind the fettered limbs, restore 
symmetry to the distorted form, give mobility to the imprisoned 
tongue, and directness to the orb of vision. 

" Like many other of the glorious achievements of surgery, it 
is based upon such simple and self-evident principles that it can- 
not but be attractive, and carry home conviction to the plainest 
capacities. Its adoption must therefore be universal ; and the 
more so, because liberally and extensively as the knife may be 
used, untwisting, as it literally does, the most misshapen and re- 
volting and convoluted masses of deformity, by dividing deep, 
yet safely, under the skin, through the thickest and broadest 
muscles ; yet are these operations, in many instances, almost free 
from jmiu, and without a drop of blood ! 

" And another remarkable feature, and one which gives the 
charm of magic to this truly brilliant triumph of our art, is the 
almost instantaneous restoration of every distorted part as soon 
as cut, and the righting of the limbs, the trunk and head, to their 
wonted beautiful symmetry and proportions, as the proud ship 
that has been bent down to the rude storm, recovers her position, 
and resumes her stately course, when the shrouds have been cut 
away." 

And further on he says : " Having myself pursued this new 
branch, as a student with my friend Guerin, for the last three 
years, and personally traced it through every step of its rapid 
progress from its birthday, I may say to its present perfect con- 



6 INTRODUCTORY, 

dition, I have thought that I could in no manner so well express 
my gratitude to him, to my country, and to my friends, for the 
kind feelings with which they have been pleased to cherish my 
name, as by attempting to found in this city of New York an 
American Orthopedic Institution, by which the principles and 
practice of that interesting science may be diffused far and wide 
through this my native land." 

It was a great and melancholy misfortune, for our age and 
profession, that his career was so suddenly terminated ; that thus 
the great desire of his life was not carried into practical execu- 
tion. 

Gentlemen, the ardent zeal with which this distinguished sur- 
geon — the acknowledged head of his profession — devoted himself 
to the study of this new branch of the healing art, is well worthy 
of your admiration and imitation. "We here see one whose name 
was already recorded in the undying history of surgery on its 
very brightest pages, and who had already won its' most brilliant 
and unfading laurels, applying himself for three long years as a 
student under the distinguished French surgeon, Jules Guerin, 
in order that he might become a perfect master of this new art. 
Strange to say, we find at the present day some young gentlemen 
complaining that three years is almost too long to obtain a per- 
fect knowledge of all the different departments of our profession. 
Yet a man who had devoted his life to this great work, who had 
more knowledge and reputation than almost any man our coun- 
try has produced, and who had performed some of the most won- 
derful operations in the world, was thus willing to devote three 
separate years to this one branch of our profession. 

You have in this fact exhibited one of the principal causes of 
this great man's most brilliant success. It was his constant and 
undeviating devotion to the study of his choice; his faithful 
application, and his unwearied toil, his determination to master 
all that genius had conceived, or industry developed, which was 
new in the profession of his adoption, which might add to its util- 
ity or give the power of relieving human beings in suffering and 
misery. It is an example worthy your imitation, and will lead 
any young man, who will make it his model, to ultimate success 
and honorable distinction. 

Dr. Henry J. Bigelow, of Boston, published a work in 1845 — 
it being a dissertation upon orthopedic surgery — which obtained 



HISTORY OF ORTHOPEDY. -7 

the Boylston Prize for 1S44, and was written on the following 
question : " In what Cases and to what Extent is the Division of 
Muscles, Tendons, or other Parts, proper for the Belief of De- 
formity or Lameness ? " It was written after studying the works 
of Guerin, Bonnet, Yelpeau, Phillips, Duval, and Little. 

The word oiihojjechj, as used by Andry, in Europe, has been 
considered as embracing the study of all deformities of the 
human frame, and in that enlarged sense we shall use it. The 
etymological composition of the technical term is evidently de- 
rived from op9bs, straight, and TrcuSevco, I educate / as such we 
shall adopt it and use it, thinking that to relieve deformities is to 
educate them straight. 

At present orthopedic surgery is but imperfectly understood 
among us, and but few feel competent to practise it. It shall be 
our endeavor so to develop this department of surgery that no 
surgeon hereafter shall feel himself thoroughly educated in his 
profession until he has also fully mastered this particular branch. 

The importance of the subject no one can deny, who pays the 
slightest attention to the numerous cases of malformation and 
deformity which we observe in every-day life. You can scarcely 
walk a block in this crowded city, or visit any of the smaller 
towns and villages of our wide-spread country, without seeing 
malformed or crippled sufferers, whose countenance bears the 
impress of mortified pride at their unfortunate condition, fre- 
quently connected with expressions of intense pain, produced by 
their abnormal physical position ; hence, the necessity of giving 
a special course of lectures on this particular department of sur- 
gery. 

My theoretical lectures, however, will form but a very subor- 
dinate part of the plan of instruction. I am restricted in the 
time allotted for the purpose, and this fact must necessarily de- 
termine the character of my lectures. I shall have no time to 
indulge in unproductive speculation and hypothesis. I shall, 
therefore, study to make my lectures brief and concise, and shall 
endeavor to make them preeminently practical. I shall illustrate 
them by cases bearing upon the rules which I shall lay down, and 
from my private as well as from my hospital practice. I shall 
bring before you cases that will demonstrate practically what I 
shall strive to inculcate theoretically. 

I can hardly lay stress enough upon the necessity of your 



S INTRODUCTORY. 

attention to these practical, clinical illustrations of the theories 
inculcated. What I lay down to you in theory, if you should 
chance to lose it, you may, if God spares your lives, some time 
find an opportunity to study out for yourselves, or hear from an- 
other, probably very much better expressed than by myself ; but, 
if you neglect the practical cases which come up before us, the 
loss can never be repaired. Therefore, you must give your close 
attention to these cases, and, no matter how much you may neglect 
the lectures, watch carefully the cases, lest you never find another 
opportunity to see them. They are the great, unfailing tests, 
which you have placed before you ; the practical tests by which 
you may know whether I am correct in the principles which I 
endeavor to teach. 

I wish, therefore, to urge upon you again to neglect no oppor- 
tunity of improving the time by strict attention to the clinical 
instruction which I may be enabled to give you. 

As I have said before, if you lose a lecture, you may make it 
up, but if you lose a clinical case, you can never make that up ; 
for, when the time comes when you would repair the damage^ 
the living illustrations of disease have departed, and the peculiar 
manifestations of the symptoms they have developed have been 
lost to you forever. 

If, therefore, I shall at any time lay down any doctrine the 
truth of which I cannot practically demonstrate and establish by 
bringing before you genuine cases to illustrate it, you are at per- 
fect liberty to discard such teaching. 

Never be governed by the ipse dixit of any man unless the 
demonstration accompanying it, or your own careful investigation, 
shall convince you that the principles enunciated are true. If, by 
means of clinical cases, I shall succeed in clearly substantiating the 
doctrines I shall teach, please endeavor to learn the precise method 
of management adopted in each case, so that whatever success I 
may secure by treatment you may also obtain. 

Such, gentlemen, is a brief outline of the history of our sub- 
ject ; the general considerations which should induce you to make 
it a subject of special study ; and the general plan which I shall 
follow in my course of instruction. 

At my next lecture I shall take up the subject of deformities 
in general, their classification, causation, and general treatment. 



DIVISIONS. 9 

LEOTUEE II. 

DEFOEMITIES. 
Definition. — Special Divisions and Definitions. — Etiology. 

Gentlemen : To-day we begin the study of deformities, their 
divisions and subdivisions, causation, and general treatment. 

DeformAty has been denned to be a morbid alteration in the 
form of some part of the body (Dunglison). 

Deformities affecting various parts of the body have received 
special names : for example, deformities of the feet are chiefly 
embraced under the general term talipes. Of talipes, however, 
we have the distinct varieties known as varus, valgus, equinus, 
calcaneus, and plantaris. 

Deformities of the spine are mainly curvatures, and of these 
we have two — the angular and lateral, or rotary lateral. 

Certain deformities are embraced in the general term hip-dis- 
ease, and, when this general term is used, the mind at once pict- 
ures to itself the characteristic deformity attending that disease. 

In the same manner have deformities of all parts of the body 
received technical names, which will be especially considered 
hereafter. 

Deformities are again divided into congenital and acquired. 

A congenital deformity is that which is present at birth. 

An acquired deformity is one which has been developed sub- 
sequent to birth. 

Congenital deformities are again divided into congenital mal- 
formations and congenital distortions. 

A congenital malformation is one in which, at birth, there is 
a deficiency or absence or increase in the number of parts be- 
longing normally to the body, or in which there are abnormal 
parts or fissures. Monstrosities are also to be classed under this 
head, and some other deformities which will be described later 
in the course. 

A congenital distortion is one in which, at birth, there is sim- 
ply a distortion of some of the normal parts of the body, such 
as most cases of club-foot, etc. 

Acquired deformities are divided into three groups : 



10 DEFORMITIES. 

1. Those arising from causes which directly affect the articu- 
lation of the body, such as complete and incomplete anchylosis, 
either of traumatic origin or due to constitutional causes, as 
scrofula, rheumatism, etc. 

2. Those arising from causes indirectly affecting the articula- 
tion of the body. Examples of this class are those deformities 
dependent upon paralysis, burns, diseases of the palmar and 
plantar fasciee, spastic contraction of muscles, etc. 

3. Those arising from causes hoth erectly and indirectly af- 
fecting the articulation of the body, such as deformities due to 
curvature of bones and interstitial softening of inter-articular car- 
tilages, etc. 

Deformities are again divided into paralytic and spastic. 

A paralytic deformity is one that has been developed in con- 
sequence of a deficiency of muscular power to retain any portion 
of the body in its normal position. For instance, I believe that 
nearly all cases of congenital talipes are of a paralytic nature. 
A paralyzed condition of one set of muscles permits the opposing 
set, contracting perhaps with only their normal force, to produce 
the deformity. This, however, will be more fully considered 
under the head of talipes. 

A spastic deformity is one that has been developed as the 
result of undue muscular contraction ; e. g., a muscle that con- 
tracts spasmodically under the reflex influence of some irritating 
cause, such as the reflex contractions accompanying disease of the 
joints, may produce a spastic deformity. 

In certain cases spastic deformities are developed upon par- 
alytic ones already existing. Such cases are not of infrequent 
occurrence, and it is this fact, without doubt, that has given rise 
to, and sustained the belief in, the spastic nature of a great 
majority of them. 

The importance of being able to recognize these different con- 
ditions at once becomes apparent, for upon such recognition de- 
pends a rational treatment. 

The question now arises, How are we to determine whether a 
given deformity is paralytic or spastic in its nature, or whether it 
is a combination of the two conditions ? In the first place, a par- 
alytic deformity can be easily overcome and the parts restored 
to their normal position by manipulation, but as soon as the re- 
taining force is removed the parts at once return to their de- 



CAUSES. 11 

formed position. If, on the contrary, the deformity is spastic in 
its nature, the resnlt of excessive muscular contraction, you will 
not be able to restore the deformed parts to their normal position 
so readily ; and, before complete restoration of the parts can be 
secured, it becomes necessary to divide the contracted tissues 
which retain them in their abnormal position, unless they can be 
sufficiently stretched to allow the parts to be replaced. 

These two conditions may be associated, and structural short- 
ening is liable to be engrafted upon paralytic deformities from 
the constant and continued contraction produced by reflex irrita- 
tion, resulting from long-continued pressure upon the deformed 
parts, such, for instance, as obtains from walking upon an abnor- 
mal part of the foot in cases of congenital paralytic talipes. This 
will be more fully explained when we come to treat of club-foot. 

The history of the case, therefore, is an essential element in 
determining whether these two conditions are associated. 

Etiology. — The causes of congenital deformities are as yet 
wrapped in such deep mystery as to preclude the possibility of 
an accurate description. They can, therefore, only be treated 
according to the condition of the patients at the time you find 
them. 

The causes of acquired deformities, on the other hand, are in 
a majority of instances quite easily ascertained. It not unfre- 
quently happens that the cause can be so readily reached as to 
prevent the occurrence of serious deformity by early attention to 
the patient ; but, if neglected, they are susceptible, more or less, 
to the correcting influences of artificial appliances and means 
which science has devised. 

Among the causes of acquired deformity we will first men- 
tion acute and chronic articular inflammation. This class of af- 
fections may produce reflex muscular contractions, which fre- 
quently will terminate in permanent deformities after the disease 
has subsided that gave rise to them. This is beautifully illus- 
trated in the deformity that accompanies hip-joint disease. In 
this instance, the deformity is gradually produced by reflex mus- 
cular contraction excited by the diseased joint ; and the deform- 
ity becomes permanent in consequence of secondary changes 
which take place in the muscles themselves. The fibres undergo 
certain changes which render them incapable of voluntary relaxa- 
tion when the cause of their contraction is removed, and some- 



12 DEFORMITIES. 

times it is impossible to extend them by force. We then have a 
contractured muscle, to which Dr. Little has applied the name 
" structural shortening," but which we have designated by the 
term contractured. When, therefore, I use the word " con- 
tractured" with reference to a muscle, I mean one that has be- 
come changed in its anatomical structure, and rendered incapable 
of elongation, either by the will of the patient or the application 
of any amount of force short of rupturing its fibres. In the lat- 
ter case, section of the contractured tissues becomes necessary be- 
fore a permanent cure can be effected. 

The effects of structural shortening are more marked in chil- 
dren than in adults. In both cases wasting of the muscles occurs 
in consequence of defective nutrition. Structural shortening of 
one or more of the principal muscles of a limb is accompanied by 
an imperfect performance of the vegetative functions ; hence, a 
greater or less lowering of temperature of the limb is almost 
always to be observed. In a great majority of instances the tem- 
perature is considerably lower than normal. 

A second cause of acquired deformities is perfect and long- 
continued rest of joints. Such rest, even of a healthy joint, will 
produce deformity by terminating in anchylosis. Here is another 
evidence of the existence of laws regulating the animal economy ; 
namely, that action is necessary for the healthy preservation of 
living tissue. The synovial fluid, for example, which is secreted 
to lubricate a joint is poured out only when the joint is in mo- 
tion. There is no waste resulting from the operation of any of 
Nature's laws ; hence, there is no secretion of synovial fluid when 
the joint is not in motion. As the eye requires light to preserve 
its healthy function, so does the joint require motion to maintain 
its normal condition; and, as the delicate orb of vision becomes 
blind when deprived of light, so does the joint fail to secrete a 
healthy synovial fluid when deprived of its normal stimulus, 
which is motion. The consequence is, if the rest is maintained 
for too great a length of time, the joint becomes permanently im- 
paired. 

In the third place, acquired deformities may be developed in 
consequence of various forms of paralysis, but especially those 
forms which are the sequelae of diseases dependent upon a blood- 
poison, such as scarlatina, diphtheria, etc. Talipes not infre- 
quently depends upon such a cause. 



PHIMOSIS. 13 

Paralysis gives rise to deformities in the following manner : 
The joints lose their support and bend outward or inward, accord- 
ing to the inclination of the joint surfaces in cases of general 
paralysis of the muscles ; or bend toward the contracting muscles 
in cases of partial paralysis. When paralysis of motion and sen- 
sation is complete, or very extensively developed, it greatly inter- 
feres with the nutrition of the part. 

Again, acquired deformity may depend upon some disease or 
injury to the spinal cord. 

Another cause of acquired deformity is the slow poisoning of 
the system by certain metallic poisons. Chief among these are 
the salts of lead, and one of the most characteristic deformities 
produced in consequence of poisoning by these salts is what is 
commonly known as " wrist-drop," caused by the use of Laird's 
" Bloom of Youth," and other villainous cosmetics. 



LECTUEE III. 



DEFORMITIES. 



Etiology (continued). — Congenital Phimosis and Adherent Prepuce. — Prognosis. — 

Diagnosis. 

Gentlemen: I shall continue the study of the causation of 
deformities to-day by first directing your attention to another ex- 
ceedingly important cause of acquired deformity, especially in 
children, namely, the reflex muscular contractions, caused by 
congenital phimosis and adherent prepuce. 

This is a cause which has been almost entirely overlooked by 
the profession in general. 

The first step in the process is an almost perpetual excitation 
of the genital organs. This excitation is followed by partial pa- 
ralysis, and this paralysis is accompanied by deformity. 

It having been my fortune to see several of these cases, I can 
do no better than to give you the detailed history of the first 
which fell under my observation. 

On the 9th of February, 1870, I received the following note : 



14 DEFORMITIES. 

" Deae Sayee : Please let me know at what hour you can come to my 

house to see the son of Mr. M , of Milwaukee. The little fellow has a 

pair of legs that you would walk miles to see. 

" Yours, truly, 

"J. Maeiost Sims. 

"No. 13 East Twenty-eighth. Street." 

I immediately went to the doctor's office, and found a most 
beautiful little boy of Rye years of age, but exceedingly white 
and delicate in his appearance, unable to walk without assistance 
or stand erect, his knees being flexed at about an angle of 45°, 
and the doctor had sent for me to perform tenotomy upon his 
hamstring tendons. 

After a very careful examination I discovered that, when I 
amused the child and distracted his attention from himself, I 
could with very little force easily extend both of his limbs to 
their normal length, but as soon as I released my hold of them 
they would instantly become flexed again, and no irritation that 
I could produce upon the quadriceps muscles was sufficient to ex- 
tend the legs except in the very slightest degree. 

I soon satisfied myself, as well as Dr. Sims, that the deform- 
ity was due to paralysis and not contraction, and it was therefore 
necessary to restore vitality to the partially paralyzed extensor 
muscles, leather than to cut the apparently contracted flexors. 

I therefore had him sent to my office for the purpose of ap- 
plying the constant current of the galvanic battery. In its appli- 
cation, while passing the sponge over the upper part of the little 
fellow's thighs, the nurse cried out, u O, doctor ! be very care- 
ful — don't touch his pee-pee — it's very sore; " and upon examin- 
ing his penis I found it in a state of extreme erection. 

The body of the penis was well developed, but the glans was 
very small and pointed, tightly imprisoned in the contracted fore- 
skin, and, in its efforts to escape, the meatus urinarius had be- 
come as puffed out and red as in a case of severe granular ure- 
thritis ; upon touching the orifice of the urethra he was slightly 
convulsed, and had a regular orgasm. This was repeated a num- 
ber of times, and always with the same result. 

The nurse stated that this was his condition most of the time, 
and that he frequently awoke in the night crying because " his 
pee-pee hurt him," and the same thing had often occurred when 
riding in the stage or car ; the friction of his clothes exciting his 
penis would cause erections. 



PHIMOSIS. 15 

As excessive venery is a fruitful source of physical prostra- 
tion and nervous exhaustion, sometimes producing paralysis, I 
was disposed to look upon this case in the same light, and recom- 
mended circumcision as a means of relieving the irritated and 
imprisoned penis. 

This I performed on the following day, assisted by Dr. 
Yale, who administered the chloroform, and Dr. Phillips, and in 
the presence of a number of my private students. The prepuce 
was pulled well forward and cut off with a pair of scissors, when 
the tegumeyitary portion readily glided back over the glans, leav- 
ing the mucous portion quite firmly adherent to the glans nearly 
to the orifice of the urethra. Seizing the thickened mucous 
membrane on either side of the glans with the thumb and finger 
nails of each hand, it was suddenly torn off from the glans penis, 
to which it was quite firmly adherent nearly to the corona. Be- 
hind the corona there was impacted a hardened mass of sebaceous 
material, almost completely surrounding the glans. This was 
removed ; the mucous membrane which had been torn off from 
the glans was split in its centre nearly down to its reflection, and, 
being turned backward, was attached to the outer portion of the 
prepuce by a number of stitches with an ordinary cambric needle 
and very fine thread. The penis was then covered with a well- 
oiled linen rag, and kept wet with cold water. 

No untoward symptoms occurred, and in less than two weeks 
the wound had entirely healed, and the penis was immensely in- 
creased in size. The prepuce was sufficiently long to cover the 
glans, and could be readily glided over it without any irritation 
whatever. 

From the very day of the operation, the child began to improve 
in his general health ; slept quietly at night, improved in his appe- 
tite, and, although confined to the house all the time, yet at the 
end of three weeks he had recovered quite a rosy color in his 
cheeks, and was able to extend his limbs perfectly straight while 
lying upon his back. 

From this time he improved most rapidly, and in less 
than a fortnight was able to walk alone with his limbs quite 
straight. 

He left for his home in the West about the 1st of April, en- 
tirely recovered ; having used no remedy, either iron, electricity, 
or other means to restore his want of power, but simply quieting 



16 DEFOEMITIES. 

liis nervous system by relieving his imprisoned glans penis as 
above described. 1 

The case that just now presents itself before us is one of this 
description : 

Case. Double Talipes Equino - Varus, Paralytica, dependent 
upon Congenital Phimosis and Adherent Prepuce. — This boy, 
C. H. "W"., aged three years, has been under treatment in a public 
institution in this city for two or three years, with the hope of 
overcoming his deformity ; and that treatment has been solely by 
the application of instruments to hold the feet in their proper 
position. The mother states that the deformity was present at 
birth ; in other words, it is congenital. As soon as he began to 
walk, his feet began to get more crooked, and have at last got 
into the shape you see here. When I take the foot in my hand, 
you see that it can be immediately restored to its normal position 
with the greatest possible ease ; and when I let go it flops around 
the ankle like the loose end of a flail. This shows that the de- 
formity is paralytic in its nature. 

In order to remove this paralytic deformity, he has worn all 
manner of machinery until both his tibial bones have been bent 
out of shape, and still he is as bad as he was at first. His general 
health is good, and he has never had any sickness which can ac- 
count for this condition of things. 

In looking about for a cause of this paralyzed condition of 
the muscles of the lower extremities, I find that the head of 
his penis has never been uncovered; in other words he has 
congenital phimosis, and adherent prepuce, as proved by the in- 
troduction of a probe. The external opening of the prepuce is 
scarcely large enough to admit the smallest probe, and as the 
probe is made to sweep around the glans the prepuce is found 
everywhere adherent, except for a few lines back from the orifice 
of the urethra. 

This penis is in an almost constant state of erection, and the 
conclusion I have arrived at is, that this boy has been the subject 

1 D. Campbell Black, M. D., in his work on " Functional Diseases of the Renal, 
Urinary, and Reproductive Organs," after reprinting some of my cases in full, says, 
page 213 : " I offer no apology for thus giving considerable prominence to the fore- 
going cases. . I attach to them immense importance, as disclosing, possibly, a frequent 
source of infantile paralysis, and the numerous indications of nervous irritability in 
childhood, while, so far as known to me, Dr. Sayre's cases are unique in medical 
literature." 



PHIMOSIS. 17 

of undue nervous irritation from genital excitement, which has 
resulted in partial paralysis of the lower extremities, and in con- 
sequence of this partial paralysis the deformity has been devel- 
oped. 

This subject of nervous irritation and consequent exhaustion 
from undue genital excitement is one of a vast deal of impor- 
tance, and has not received the attention at the hands of the pro- 
fession that it justly deserves. The pressure continually exerted 
upon the glans penis by the contraction of the adherent prepuce 
keeps the ^organ in an almost constant state of irritation and erec- 
tion. 

Such a constant genital excitement, no matter what its cause 
may be, whether occurring in a child or in an adult, is certainly 
detrimental to the best condition of the nervous system. In the 
class of cases before us, this undue genital excitement ends in 
paralysis, and the consequent deformity varies according to the 
manner in which the weight of the body is placed upon the foot. 
A simple mechanical support will restore the foot to its normal 
position, but the child can only be relieved permanently of the 
deformity by removing the cause which has given rise to the 
paralysis. The first step, then, to be taken toward curing this 
case is to perform the operation of circumcision, and liberate the 
glans penis from the adherent prepuce ; for I am firmly of the 
opinion that the paralysis in this case is the result of nervous irri- 
tation from genital excitement which is caused by this adherent 
prepuce. [The operation was performed.] The child will be re- 
turned at the end of two weeks, and we shall then see whether 
any benefit has been derived from the operation. Meanwhile, 
no dressing whatever will be applied to the distorted feet, in 
order that we may see what effect this nervous affection had in 
producing the deformity. 1 

1 The mother returned at the end of the two weeks, stating that the child had 
been perfectly quiet every night since the operation, sleeping without any disturbance, 
and passing his water without difficulty, which had never occurred before. He ate 
well, was very much improved in his general appearance, and could stand flat on his 
feet without any assistance. Upon stripping the child's feet the mother's statement 
was fully corroborated, as will be seen by the annexed figure (Fig. 1), which was 
taken immediately after by Mr. Mason, photographer to Bellevue Hospital, just two 
weeks from the operation. As will be seen, the child stands perfectly flat upon the 
feet, with simple inversion of the great-toe of the left foot, The increased muscular 
power without the use of anv electricity has been almost marvelous, and now by the 
2 



18 



DEFORMITIES. 



We will add another case of reflex paralysis, which beauti- 
fully illustrates the rapidity with which the muscles regain their 
power of contraction, and also how readily they will respond to 




the directions of the will when the source of irritation is re- 
moved. 

Case. — T. B., aged three years and eight months, was brought 
to me by Dr. P. Brynberg Porter, of 65 West Forty-eighth Street,. 
on the 1st of June, 1875, to be treated for paralysis of the lower 
extremities and prolapsus of the rectum. 

The doctor had detected the phimosis and constant priapism, 
and, suspecting that it might possibly be the cause of his trouble, 
brought him to me for examination. 

The child was very peevish and fretful, very costive, and the 
mother states that " in straining at stool and in making water his 
bowel would frequently come down, and give her great trouble in 
pushing it up." 

application of the galvanic current to the peroneal muscles we have a prospect of the 
perfect recovery of the child without any further mechanical support. 



PHIMOSIS. 



19 



He began to tumble down very frequently about a year ago, 
and was growing more and more clumsy in walking. He could 
not stand alone without support, and even when supported bis 
legs would bend in different directions, as seen in Fig. 2, from a 
photograph by O'Xeil, June 1, 1875. 




Fig. 2. 



He was circumcised on the 2d of June. The lining mem- 
brane of the prepuce was firmly adherent to the glans, requiring 
section by the knife before it could be torn off. Behind the coro- 
na was the usual hardened smegma, which had produced erosion 
of the mucous membrane. 

The parts were dressed with an oiled rag and cold water. 

June Hh. — The boy could stand without support, and had 
slept quietly the past two nights. 

At the end of twelve days he was entirely well ; could walk 
and run without tripping, and his bowels had become perfectly, 
regular, without any prolapsus. 

The annexed photograph by O'J^eil, taken July 1st, shows 
the improvement in his limbs. 



20 



DEFOKMITIES. 



In the picture taken June 1st, his shoes had to be laced tight- 
ly around the ankle to enable him to stand even with support ; 




but in that taken July 1st (Fig. 3), it will be seen that he stands 
erect without any assistance. 

One of his limbs is slightly abducted in the photograph, but 
that was on account of his restlessness — it is not so constantly. 1 

In continuation of the subject of causation, we next observe 
that deformities of the spine occur most frequently during the 
period of growth and development. Young girls are more dis- 
posed to have the so-called lateral curvature of the spine than boys, 
for the changes which their systems undergo during this period 
of growth and development are more marked than those which 
take place in boys, and occur just at the time when the bony 
structures are more or less pliable and not fully developed. 

Certain derangements in the health are also to be noticed in 

1 For a more full report of injury to the nervous system by irritation of the genital 
organs of both sexes, see author's paper in " Transactions of the American Medical 
Association," for 1875. 



PROGNOSIS. 21 

this connection as causes for deformities. Diseases caused by 
sedentary habits, such as dyspepsia, hypochondriasis, melancholia, 
etc., frequently seem to give rise to rotary and lateral curvature. 
It is in this class of cases that your efforts toward effecting a 
cure will be most unsatisfactory ; for you have to deal with a 
loss of power, and an extreme sensitiveness to all influences, es- 
pecially heat and cold, which, combined with other derangements 
of the nervous system, render these cases very intractable. 

The last kind of cause of acquired deformity which I shall 
mention here is the traumatic. 

Under this head may be embraced blows, bruises, burns, 
wounds, etc. 

Most of those causes which have been indicated, as well as 
those which have not received special mention, will be more 
fully considered as we proceed with our lectures, for subsequent- 
ly I shall dwell more fully upon the special causes of each de- 
formity, which have thus far been referred to only in a general 
way. 

Pkogxosis. — In general, your prognosis should be extremely 
guarded. There are very many exceptions, it is true, to this 
general rule, but to those exceptions your attention will be di- 
rected further on in the course. In the treatment of deformities, 
particularly those of long standing, you will find that the prac- 
tical application of the principles which are to guide you, how- 
ever simple these principles may be, will in many cases be ex- 
ceedingly difficult. You may be led, on account of the seeming 
simplicity of many principles which are to be laid down, to an- 
ticipate speedy relief and rapid recovery ; but in a majority of 
cases you will really be very much disappointed. Your faith in 
being able to produce rapid improvement by the treatment of 
deformities of long standing will be very much weakened, when 
you come to have a few such cases under your own personal ob- 
servation and care. Nevertheless, it may truthfully be said that, 
with patience and perseverance in the right direction — these are 
words full of meaning — you will be able, in a majority of cases, to 
accomplish such results as will be extremely satisfactory to the 
friends, and more than compensate you for your extra labor. In 
some cases, the improvement will be so rapid that it will become 
a source of great astonishment to you. In general, however, 
such results are not to be obtained. There is one exceedingly 



22 DEFORMITIES. 

important element in the management of all cases of deformity, 
and it is one which will materially affect your prognosis, namely, 
the cooperation of the patient. If the hearty cooperation of the 
patient can be obtained, a long step has been taken toward effect- 
ing a permanent and complete cure. 

The lame, the crooked, and deformed, are all influenced men- 
tally by their misfortunes. In many instances, I have seen the 
strongest evidence of this influence upon the mind : one in par- 
ticular I will mention, which is that of a young girl who was 
brought to me, to be treated for chorea in a very aggravated 
form. 

As this case is a beautiful illustration of the principle we are 
now speaking of, I cannot do better than refer to it here, although 
I have already published it in the New York Journal of Medi- 
cine for 1849. 

Case. Chorea induced by Anxiety, on Account of a Deform- 
ity / and cured by Removal of the same. — Mary Pheeny, Pearl 
Street, aged sixteen, was brought to me in March, 1848, for 
chorea, with which she had been afflicted for two years previous ; 
she had also had several epileptic convulsions. 

She was a large, robust, healthy-looking girl, but exceedingly 
desponding and gloomy, almost an idiot in appearance, wishing 
to be by herself, and seldom speaking to any one. 

She was strangely deformed in her feet and one hand ; having 
ten toes on her left foot, and eight on the right, with their proper 
number of phalanges, and each articulated with a separate meta- 
tarsal bone, except the second and third on the left foot, which 
were joined together, so as to resemble one toe with two nails, 
which gave that foot the appearance of but nine toes ; but after 
their removal I found a double row of phalangeal bones, inclosed 
in a common tegumentary envelope. 

On the right hand she had five fingers, besides an extra joint 
upon the thumb. 

Upon taking hold of her hand, my attention was drawn to her 
extra finger, and when I alluded to it she gave an hysterical sob, 
followed immediately by a severe convulsive fit, caused, as her 
mother informed me, by my allusion to her deformity, as she was 
exceedingly sensitive upon that point. 

After talking to her mother a few moments, she wished me 
to look at her feet, as they were also deformed ; and, upon my ex- 



CASE. 23 

amining them, another convulsive fit was induced, which led me 
to believe that the cause of .disturbance in her nervous system, 
upon which these fits and the chorea depended, was anxiety of 
mind about her deformity ; and she had pondered on it so con- 
stantly, and let it obtain such complete control of her nervous 
system, that any allusion to her misfortune would be immedi- 
ately followed by a fit. 

After examining the case carefully, I found every organ 
healthy, and all their functions properly performed. She had 
been under treatment for some time past, for suppressed men- 
struation, which had been successful ; and for the last two months 
her menstruation had been perfectly regular. 1 

Therefore, finding no other cause to which I could attribute 
this derangement of her nervous system, I was compelled to be- 
lieve it caused by anxiety on account of her deformity, and 
advised the removal of her extra toes and finger, to which she 
readily assented. 

From that moment her countenance assumed a cheerful, smil- 
ing aspect, she laughed and talked half hysterically, and walked 
about with almost a frenzied delight, and exhibited not the 
slightest evidence of chorea. She was exceedingly anxious to 
have the operation performed at once, but it was deferred in 
order to take the casts, from which the accompanying drawings 
were made. (See Figs. 4 and 6.) 

On the 9th of March, assisted by Drs. Trudeau and Yan 
Buren, I removed her supernumerary toes, having first put the 
patient under the influence of ether, which had the desired effect 

1 Dr. Porcher, now of Charleston, who treated her for some time, has published 
the case in the Charleston Medical Journal and Review for March, 1848, and states 
that she was perfectly cured in four weeks, by the use of carbonate of iron and rhu 
barb. 

If he had reference to her menstruation simply, he would have been correct. But, 
in including in the word cure the chorea and epilepsy under which she labored (as I 
presume he does, for he has headed his article " St. Yitus's Dance "), he is evidently 
mistaken ; for her gait was exceedingly unsteady when she came to my office, and the 
fact of her having two convulsive fits upon my alluding to her deformity proves that 
her epilepsy and chorea still continued ; and it is to correct this statement that I have 
by the advice of several medical friends made the case public. 

She was not 'relieved of her chorea and epilepsy until she was assured that her 
deformity could be removed: from that moment her countenance assumed a cheerful 
aspect, and her chorea and epilepsy left her entirely, without any medical treatment 
whatever, and have never returned. 



24: 



DEFORMITIES. 



of benumbing all sensation, and, when restored to consciousness, 
she expressed great surprise at their removal. 

The parts were brought in close apposition by sutures, straps, 
and firm bandages, and dressed with cold water. Union of the 




Pig. 4. 



Fig. 5. 




Fig. 6. 



Fig 7. 



whole wound, in each foot, took place by first intention without 
the formation of any pus, and in twenty-three days after the op- 
eration she walked to my office (nearly one mile), and the second 
casts were taken from her feet, from which the improved draw- 
ings were made. (See Figs. 5 and 7.) 

The most singular feature in this case is, that, from the mo- 
ment she became convinced that her feet could be improved, her 
chorea left her, and has not returned ; neither has she had a sin- 
gle epileptic convulsion. 

I removed the extra finger under the influence of chloroform, 
at the carpo-metacarpal articulation, by a straight incision on the 



TREATMENT. 



25 



back of the hand. The wound united by first intention, and the 
hand looks quite natural, as is seen by contrasting Figs. 8 and 9. 




Fig. 8 



Diagnosis. — The rules for making a diagnosis will be consid- 
ered in connection with the study of each deformity. 



LECTUBE IV 



DEFORMITIES. 

Treatment. — General Principles. — Operative Treatment. — Tenotomy. — Myotomy. — Te- 
notomes. — Breaking up of Bony or Fibrous Anchylosis. — Anaesthetics. 

Gentlemen : To-day we begin the study of treatment of de- 
formities, and I will first invite your attention to the considera- 
tion of certain general principles. 

Treatment. — The treatment of congenital deformities should 
commence early. This rule is especially to be observed in all 
those cases in which the deformity depends upon disorders of 
muscular power that are of a paralytic nature. When we come 
to speak of the treatment of congenital club-foot, we shall insist 
very strongly upon the recognition of this principle. 

The great reason why treatment of this class of deformities 
should be commenced early is, the hope of preventing irritation 
or inflammation of the parts abnormally pressed upon, as well as 
the muscles and f ascise involved, which may add a spastic deform- 
ity to the already-existing paralytic one. 

Again, early treatment is important for the sake of prevent- 



26 DEFORMITIES. 

ing the development of serious nervous diseases. For example, 
in the case already alluded to, the girl was suffering from chorea, 
or something analogous to it, because of the impression made 
upon her nervous system by the presence of her deformity, and 
she became perfectly well the moment she was satisfied that it 
could be rectified. Her case, therefore, furnishes strong proof 
of the necessity of attending early to the correction of any such 
malformations. 

Acquired deformities can very frequently be prevented by 
early attention to the underlying disease which produces them ; 
and, as the knowledge of how to prevent deformities is equally as 
important as how to treat them when they are fully developed, 
the diseases upon which such acquired deformities may depend 
will be very fully considered in our subsequent lectures. 

We now come to the consideration of the subject proper. The 
treatment of deformities may be divided into operative, and that 
by means of mechanical appliances, manipulation, the applica- 
tion of electricity, the use of drugs, etc. 

Under the head of operative treatment, we have tenotomy, 
myotomy, and breaking up of bony and fibrous formations. 

By the term tenotomy we mean section of a tendon. The in- 
strument commonly employed for this purpose is called a teno- 
tome. Myotomy means section of a muscle. 

When it is necessary to divide fascia or fibrous bands, they 
are to be cut in accordance with the general rules which govern 
the division of muscles Or tendons. The history of tenotomy and 
myotomy has already been referred to in our introductory lecture. 

For the purpose of performing these operations, you will re- 
quire knives or tenotomes having a peculiar construction. The 
handle of the instrument should be so constructed that you may 
always know in which direction the edge of the blade is turned 
(which may be indicated by a dark spot upon the handle). If this 
precaution is not taken, when the blade is buried deep beneath 
the tissues, you will be ignorant of the exact direction of the cut- 
ting edge, a thing always to be borne in mind. The shank should 
be strong, and firmly inserted into the handle. Its length should 
be from one inch to one and three-quarters inch, with a blade 
three-quarters of an inch to an inch in length, according to the 
size of the tendon to be divided. The blade should be made very 
thick at the " heel," very narrow in the cutting portion, and always 



TENOTOMY. 27 



blunt-pointed. The point should be somewhat rounded, and 
sharpened from side to side like a wedge or chisel, so that when 
introduced it splits rather than punctures the tissue through which 
it passes. {See Fig. 10.) The instrument should be made of the 



Fig. 10. 



finest-tempered steel, otherwise so small a blade as this, in cutting 
through .a permanently contractured tendon or fascia, or any por- 
tion of tissue that has undergone structural change, is very liable 
to be broken. These blades are made of various shapes ; some 
straight, and some curved, with the cutting edge either on the con- 
vex or concave border. The sharp-pointed tenotomes usually 
found in the shops should never be used, as they are liable to 
puncture tissues which should be unmolested ; and their use in the 
neighborhood of important vessels and nerves is very hazardous. 

The next important question is, How are we to determine 
whether, in any given case, we shall be compelled to resort to 
tenotomy ? 

The law, which is of universal application in deciding this 
question, is the following : Place the part contracted as nearly as 
possible in its normal position, by means of manual tension grad- 
ually applied, and then carefully retain it in that position ; while 
the parts are thus placed upon the stretch, make additional point- 
pressure with the end of the finger or thumb upon the parts thus 
rendered tense, and, if such additional pressure produces reflex 
contractions, that tendon, fascia, or muscle, must be divided, and 
the point at which the reflex spasm is excited is the point where 
the operation should be performed. 

If, on the contrary, while the parts are brought into their nor- 
mal position by means of manual tension gradually applied, the 
additional point-pressure does not produce reflex contractions, the 
deformity can be permanently overcome by means of constant 
elastic tension, and the more you cut the greater will be the 
amount of damage done. This is an important law, which you 
will do well to remember ; for its application, as already re- 



28 



DEFORMITIES. 



marked, is universal in deciding the question of cutting con- 
tracted tissues. Even when the parts can be completely restored 
to their normal position, by means of manual force gradually ap- 
plied, if this additional point-pressure produces pain or spasm, 
the contractured tissue must be cut before a complete cure can 
be effected. 

The next question that arises is, How is the operation to be 
performed ? 

1. By your own hand or by that of an assistant, put the parts 
to be cut fully upon the stretch. 

2. Make the cut subcutaneously, and thrust the tenotome 
through the integument at such an angle as will make a valvular 
incision. (See Fig. 11.) 




Fig. 11. 



3. Introduce the tenotome flatwise {see Fig. 11). Carry the 
end of the knife through the tissues slowly until the tendon 
is reached ; then carry the blade flatwise beneath the tendon to 
its opposite side, and turn its cutting edge toward the tendon 
(here you see the importance of having the handle of the teno- 
tome marked in such a way as will indicate the direction in which 
the cutting edge is turned), and then press the tendon down upon 
the edge of the blade, at the same time giving the instrument a 
slightly sawing motion until the tendon gives way, which can be 
recognized by the finger, and not infrequently by an audible 
snap. It is exceedingly important that your section of the ten- 
don should be complete, otherwise the deformity will remain un- 
less you forcibly rupture that portion which you have failed to 



POSITION AFTER TENOTOMY. 29 

cut. The instant the tendon is severed, the instrument is turned 
flatwise and withdrawn. As it is withdrawn, slide your finger or 
thumb over the wound, thus forcing out any blood that is in the 
track of the knife, and preventing the entrance of air. The 
wound should then immediately be hermetically sealed with ad- 
hesive plaster, being careful under no circumstance to carry the 
plaster completely around the limb, and the plaster be secured in 
its position by a roller-bandage. The application of these- princi- 
ples will be fully illustrated when we come to the treatment of 
special cases. 

The next important question is, Shall the parts after section 
of the contractured tissues be restored as nearly as possible to 
their normal position at once ; or shall a delay be made of a few 
hours, or a few days, until the external wound has permanently 
closed, and the inflammatory action which may follow the opera- 
tion has subsided ? For many years my teaching was to secure 
the limb in its deformed position until the external wound 
had closed, and the inflammatory action had subsided ; but at 
present it is, that the deformed parts should be restored at 
once as nearly as possible to their normal position. This is 
the general rule which I feel willing to lay down as the one 
which should govern you in the majority of cases, but to this 
rule there are notable exceptions. In all deformities dependent 
upon abnormal muscular action alone, whether paralytic or spas- 
tic, restore the parts as nearly as possible to their normal position 
immediately after section of the contractured tissues has been 
made. In all cases, however, of acquired deformity which depends 
upon previous disease of a joint, terminating in fibrous anchylo- 
sis, and in which section of the contractured parts becomes neces- 
sary, the division should be made, and the external wound be 
permitted to heal before resorting to force for the purpose of 
breaking up the anchylosis. If motion and force are applied in 
this class of cases immediately after section has been made, air 
may enter the wound, inflammation follow, and suppuration be 
established. 

The breaking up of bony or fibrous anchylosis, such as is 
liable to occur in connection with joint-disease, may be accom- 
plished by muscular or mechanical force. In many cases the 
breaking-up process and the cutting operation are both necessary 
before the distortion can be corrected. The special treatment to 



30 DEFOKMITIES. 

be adopted in this class of cases will be mentioned when we come 
to the consideration of complete and incomplete anchylosis. 

Anesthetics. — Shall we use anaesthetics in orthopedic opera- 
tions ? 

A majority of operations for the relief of deformities of the 
foot I prefer to perform without resorting to their use. The 
pain connected with the operation is very slight, hence the ad- 
ministration of an anaesthetic is not necessary as an act of human- 
ity. The child cries through fear of the knife principally ; and 
there are some instances in which the nervous system of the pa- 
tient is such, that great fright may bring on convulsions. Of 
course under such circumstances the administration of an anes- 
thetic is proper. The contractured tendons should be brought 
into as bold relief as possible, and the irritation produced by the 
crying of the child will cause an additional contraction, that will 
bring it more distinctly into view. In all the more severe opera- 
tions, anaesthetics should always be used. 



LECTUEE V. 



DEFORMITIES. 



Treatment (continued).— Mechanical Appliances —General Principles governing their 
Use. — Elastic Tension. — Adhesive Plaster. — Electricity. — Instrument for testing 
Muscular Tissue. — Cases. 

Gentlemen : We will continue the study of our subject this 
morning, by first directing our attention to the employment of 
mechanical appliances in the treatment of deformities. Such ap- 
pliances are of great service, and, in fact, are very essential. 

Until very recently the use of mechanical contrivances has 
been the most valuable means of rectifying deformities possessed 
by the orthopedic surgeon, but, with the improvements we now 
have at our command, we are enabled to do more toward the 
restoration of a deformed part in a single day than could for- 
merly be done in weeks or months. Restoration in fact is, in 
many instances, only possible when the operation is followed by 
a properly-applied apparatus. 



THE ESSENTIALS OF AX APPARATUS. 31 

Great ingenuity has been displayed in the manufacture of 
different instruments, and many complicated contrivances have 
been devised for the application of mechanical force. Occasion- 
ally, demand upon the ingenuity and skill of the mechanic is 
required ; but, as a general rule, elaborate and complicated in- 
struments should be avoided. The principal requisites of an 
orthopedic apparatus are, simplicity, facility of application, and 
lightness as far as compatible with the object to be accomplished 
by its use. It should never encircle a limb or trunk in such man- 
ner as to interfere with the circulation, nerve-currents, or natural 
movements of the part. I would caution you against such inter- 
ference. You can all easily understand that, if the muscles and 
the vessels supplying them — the nerves, veins, and arteries — 
should be girdled with straps or heavy instruments, binding them 
down upon the bone, the effect would be to obstruct the supply 
of blood to the limb, with its attendant disaster, gangrene. 
Thus, a baclly-contrived instrument will rather add to the gravity 
of a case than relieve it. For an apparatus to be truly useful, it 
should be as simple in its construction as circumstances will per- 
mit, and should compress the limb in its circumference as little 
as possible. It should act in its tractile force gradually and con- 
stantly, and, as the line of deformity is slowly changing its direc- 
tion, it becomes very necessary that the apparatus be frequently 
removed and reapplied,, or adapted to the new line of distortion. 
The persons in charge of, and using the apparatus, should thor- 
oughly understand their manner of action, be perfectly acquaint- 
ed with their mechanism, and the object to be gained by their 
application. At the outset the practitioner should adapt the in- 
strument to the deformity, and not the deformity to the instru- 
ment, as is too frequently attempted. Proceed in a gentle man- 
ner until the first difficulty is overcome. The pain experienced 
in the part soon wears off as the mind becomes more tranquil, 
and then you can, day by day, bring to bear upon it such force 
as will tend to secure the desired object. 

In the use of any apparatus, if you put on the screws and 
straps by which it is adjusted, and tighten or loosen and 
strengthen them as opportunity offers without any order or de- 
sign, you are liable to increase the existing difficulty and to retard 
recovery. Therefore, you must make it your maxim in these 
cases to " make haste slowly." The principle which should con- 



32 DEFORMITIES. 

trol your action in the treatment should be, never advance too 
rapidly, lest it arrest the process of cure ; by steady and appro- 
priate progress your object is really earlier accomplished, and usu- 
ally without risk. 

In the choice of a mechanical apparatus you should be guided 
not only by its adaptability to the member to which it is to be 
applied, but also by your acquaintance with its mechanism and 
use ; and you should be positive that you understand the prin- 
ciples upon which it is constructed before you purchase or at- 
tempt to use it. Get true principles of treatment into your heads, 
and then design some form of mechanical apparatus, if necessary, 
to put them into practical application. 

There is another important rule which should influence your 
management of all paralytic deformities, and also many other 
cases, especially those in which it becomes necessary to overcome 
muscular contraction, or to retain muscles in a state of rest for a 
considerable length of time; it is this: permit as far as possible 
the natural motion in the parts involved in the deformity. 

The joints and muscles of the human body were designed by 
the Creator of all things for active motion, and as far as is prac- 
ticable the natural movements of the body should be retained, 
stimulated, and strengthened. It is for this reason that all treat- 
ment of paralytic deformities by means of fixed apparatus is to 
be condemned. The total, absolute rest which must necessarily 
occur in a muscle when secured in some fixed apparatus, if too 
long continued, will certainly induce such structural changes as 
will preclude all possibility of ever overcoming the deformity by 
restoring to the muscle its normal power. 

Elastic Tension. — As has already been stated, subcutaneous 
tenotomy was first applied to the relief of deformity in the year 
1830 by Stromeyer. That operation marked a new era in ortho- 
pedic surgery, and for many years the operation of tenotomy was 
exclusively relied upon for affording relief of the contracted 
tendons. 

Yet, in the progress of time, we have learned still more ; and 
in my own experience I have been enabled to test the correctness 
of the now established principle of extending a contracted muscle, 
by the constant application of an elastic force, moderately but 
persistently applied. This will, in the majority of instances, 
accomplish the object fully as efficiently as tenotomy, where the 



ELASTIC TENSION. 33 

muscle has not already undergone structural changes, or, in other 
words, become contract ured ; and it is infinitely better for the 
future usefulness of the limb involved, although sometimes much 
more tedious in producing the result. 

I have made use of elastic extension, by means of India-rub- 
ber, ever since my pupilage, having been taught its value by my 
preceptor, the late Dr. David Green. The difficulty in its appli- 
cation, in many instances, without expensive and cumbersome 
machinery to secure its attachment, in order to obtain its force, 
was the only obstacle to its universal employment. 

This difficulty has been happily overcome within a few years 
by the simple yet beautiful contrivance first suggested by Mr. 
Barwell, of London, whereby we can secure the attachments, for 
the origin and insertion of the elastic power, to any part of the 
body, by the use of small strips of tin made permanent at the 
place desired, by means of adhesive plaster and a roller. In this 
way we can imitate the action of almost all the muscles of the 
body. We get rid of the weight of cumbersome machinery, 
which is so serious an inconvenience in all paralytic deformities, 
and the persistent action of the elastic during the hours of 
sleep — which is Nature's anaesthesia — renders it an agent of 
most wonderful power, capable of overcoming an immense num- 
ber of serious deformities. 

This suggestion of Barwell's will make almost as great an ad- 
vance in orthopedic practice as did the suggestion of Stromeyer 
of subcutaneous tenotomy. The rules for its application, and the 
diagnostic differences of the cases where it is applicable from 
those where the knife becomes a necessity, I shall lay down more 
fully in my future lectures. 

Adhesive Plaster. — In all cases where it is desirable to main- 
tain long-continued traction by means of adhesive plaster, the 
most reliable article that can be used is that manufactured by Mr. 
Maw, No. 11 Aldersgate Street, London, and known by the name 
of "Maw's Moleskin Plaster." Plaster spread upon Canton 
flannel may be used, but it is not nearly as good as the " Mole- 
skin Plaster." 

I receive complaints almost daily from doctors in the country 

that they cannot make the plaster stay on more than a day or 

two. In the first place, they put it on too hot ; the heat destroys 

the vitality of the epidermis, and it peels off the same as from a 

3 



34 DEFORMITIES. 

blistered surface, and, of course, carries with it the point of at- 
tachment. In the next place, they do not thoroughly knead the 
strips of plaster and mould them uniformly to the limb before 
subjecting them to the strain of traction. If a reliable article is 
used, and these precautions taken, there need be no trouble with 
regard to making the plaster adhere firmly to the surface. As an 
additional precaution, however, it is important that the surface 
to which the plaster is to be applied should be clean and dry. 
There is another exceedingly important point relating to its re- 
application, as in a second dressing : when the plaster has been 
on a limb for a long time, and then removed, there will be found 
more or less dead scarf-skin on the surface ; this must be com- 
pletely removed before making another application of plaster ; 
we must have a clean, solid surface in order to get a firm foot- 
hold, so to speak. If the plaster is applied over the dead skin 
which is found remaining on the surface, it would be like fresco- 
ing an old wall without cleaning it ; your labor would be in vain, 
and your money lost ; so here, if you apply the plaster before the 
dead epidermis is removed, you will run the risk that it will blis- 
ter the surface in some places, while it fails to adhere in others ; 
and the whole object of the dressing will be defeated in conse- 
quence of neglecting to take this seemingly trivial precaution. 

The surface of the limb can be very easily cleansed by first 
applying a small quantity of sweet-oil, and afterward removing 
this with soap and warm water. If the surface becomes broken 
in removing the old plaster, the new should not be applied until 
all abrasions or fissures are thoroughly healed. In some cases it 
may be necessary to place the patient in bed for a few days, or 
resort to some modification of the apparatus which is employed, 
in order to secure a healthy, clean surface, to which the plaster 
can be reapplied. 

This matter of selecting a proper kind of plaster, together 
with directions regarding its application, and the precautions to 
be taken, may appear to you like insignificant items ; but they 
are really very important. For, unless you have a reliable adhe- 
sive plaster (the ordinary kinds in common use being worthless 
for this purpose), all your efforts at long-continued traction will 
prove entirely useless, and your plan of treatment will utterly 
fail. The value of this agent, and the necessity of using a reli- 
able article, will be demonstrated farther on in the course. 



ELECTRICITY. 35 

Electricity. — Of the theories respecting the modus operandi 
of this agent I do not propose to speak. Its apparent value as a 
means for restoring vitality to paralyzed muscles is indisputa- 
ble. There are a few rules which should regulate its application, 
and it is to these alone that I purpose calling your attention. I 
regard them of the utmost importance, and therefore ask your 
careful attention to their observance : 

1. When applying electricity for the restoration of paralyzed 
muscles, do not apply it too long. Three or five minutes every 
day, or every other day, is sufficient in a majority of cases. 

2. Do not apply it too strong. A strong current is very like- 
ly to give rise to over-fatigue of the muscles ; this effect is espe- 
cially liable to be produced when such a current is continued too 
long. Over-fatigue of the muscles induced in this manner will 
be as positively injurious as that induced by any other means, 
and all over-fatigue of paralyzed muscles must be carefully 
avoided. 

3. Always restore the muscle as nearly as possible to its nor- 
mal position, by means of some artificial support, and retain it 
there, approximating its origin and insertion before the battery is 
applied. The principle is, the paralyzed muscle should be placed 
in such a position that, when stimulated to contract in response to 
the electric current, it can do so without carrying any weight. If 
a paralyzed muscle is compelled to act without this assistance, per- 
manent damage rather than permanent benefit will be likely to 
result. 

You will always recollect, therefore, to approximate the origin 
and insertion of all paralyzed muscles before applying the electric 
current. Muscles that have entirely lost their excitability upon 
application of the electric current, are incapable of contraction. 
The production of even a few contractions will indicate to you 
that treatment persistently applied will finally greatly increase the 
power of the muscles. But if the contractions are forced, as is 
exceedingly apt to be the case unless great care is exercised, it 
will be found that, perhaps, the next day no contractions can be 
obtained. The slight power of contraction which some muscles 
may have is, doubtless, many times entirely destroyed by the 
excessive use of the electric current, the muscles being over- 
fatigued by this stimulus the same as they would be by over- 
work. 



36 DEFOEMITIES. 

For the purpose of determining whether a muscle has un- 
dergone fatty degeneration, it is only necessary to remove a 
small portion by instruments specially devised for that purpose, 
and then submit it to microscopical examination. (See Fig. 12, 



Fig. 12. 

Duchesne's instrument for removing muscular tissue:) One pre- 
caution, however, is to be taken, namely, to examine the muscle 
suspected at different points from one end to the other. When 
this has been done, your prognosis can be established relative to 
the restoration of lost muscular power by means of the electric 
current. The principles here referred to are well illustrated by 
the following cases : 

Case. May 22, 1867. — Mary C, aged eleven years; father 
died seven months before her birth, of softening of the brain ; 
mother was healthy, and child robust and healthy until nine 
months old. She was put to bed one night in perfect health, 
and was found in the morning paralyzed in both arms and legs. 
In a few weeks the arms and right leg partially recovered — the 
arms are well at the present time. The right leg again became 
paralyzed a year ago. 

There is talipes equino-varus of the right foot, and valgus of 
the left. Both limbs are very much atrophied, but the left much 
more than the right. The right limb responds to the galvanic 
current ; the left limb gives no response in any of its muscles, and, 
testing the muscles by Duchesne's method, they were found to 
be fatty. This test was applied by a single puncture to the gas- 
trocnemius and also one to the quadriceps femoris, and, they 
proving in both instances to be fatty, I gave an unfavorable prog- 
nosis respecting that limb, and stated to the family that treat- 
ment of it would be useless, as it never could recover. 

The tendo-Achillis of the right leg and the biceps and outer 
hamstring of the same limb were contracted, but, yielding under 
elastic tension and giving no reflex spasm on point-pressure, were 
not divided. After continued application of electricity to the 
paralyzed muscles of this limb, bathing with hot-water and the 
application of elastic tubing to assist the paralyzed muscles, her 



APPLICATION OF ELECTRICITY. 37 

general health was much improved and the right leg increased in 
size. 

After some weeks of treatment I accidentally applied the bat- 
tery to the left limb, and was surprised to find muscular contrac- 
tion. I called the attention of my assistant to this fact, and again 
applied the battery to show him that the muscle responded, when 
no response was given. He replied that he was certain there was 
no contraction, as he had examined that muscle under the micro- 
scope and found fatty degeneration, and, as we could not make it 
contract under the current, I concluded that he was correct, and 
that possibly I might have been mistaken in my first observation. 
Three days afterward, in making the same experiment, the mus- 
cles gave an evident response ; and, not wishing to be mistaken a 
second time, I repeated the experiment quite a number of times 
and satisfied myself that the muscle responded to the battery, and 
again calling the attention of my assistant to this muscular con- 
traction, and applying the battery, obtained — no result. Two 
days afterward, upon making the same experiment, the mus- 
cles contracted, when the attention of my assistant was again 
drawn to the fact, and we both observed the contractions very 
distinctly. These contractions were repeated quite a number of 
times during the space of a minute, and then ceased altogether, 
and no force that we could apply with the battery would obtain 
any response. 

Two days afterward the same experiment was performed, 
with precisely the same result, showing that the paralyzed 
muscles can make but few responses to the galvanic current 
without becoming so much exhausted as to require repose, and 
that we should, therefore, never continue our application too 
long in these cases. 

Another fact was proved by this case, that although the points 
of the muscles that were examined proved to be fatty, there 
must have been some other portion of the muscles that had not 
yet undergone this change; and, consequently, before we can 
pronounce the case absolutely hopeless we must explore the 
muscles their entire length in different places. 

I had already applied an instrument to the other limb, but 
had done nothing for the left one, having considered it useless 
to do so. I now, however, applied an instrument to this leg also, 
which permitted all the> natural movements (see Fig. 13), the 



38 



DEFORMITIES. 



power of the left thigh being supplied mostly by springs work- 
ing over the knee-joint of the instrument. The right foot is 




Fig. 13. 



kept in position by an elastic strap running from toe of shoe 
to a belt around the leg above the calf; two horizontal steel 
pieces, with joints at the ankle, extend from the sole of the shoe 
to this belt. {See Fig. 13.) 

This girl had been for seven years under treatment in an 
orthopedic institution, so called, where she had worn a long iron 
splint on the left limb, having neither a joint at the ankle nor 
knee, and nothing had been done for the right leg. 

July 11, 1867. — She can now, by the aid of the instruments, 
stand alone and take one or two steps. With crutches walks 
well, putting one foot before the other. She has improved 
greatly, generally as well as locally, and returns home to con- 
tinue treatment. The contraction of right leg is greatly im- 
proved. 

The following extracts from letters show the progress of the 
case: 



ACTION OF ELEOTEICITY. 39 

" October 14, 1867.— She has gained eleven pounds in weight. The left 
leg (the worst one) measures one inch more in size, both above and below 
the knee, and she is able to move it a little in various ways in which she 
could not move it formerly. The right leg is much straighter at the knee." 

" July 20, 1868. — Mary's foot is now quite well, and she improves constant- 
ly in using it, and she walks with comfort. 

" Very respectfully, E. 0." 

Remarks.— The facts observed in this case respecting the 
action of the galvanic current on the muscles of the left leg, 
brought to my mind another case in which I had abandoned the 
treatment two years previous, on account of no muscular con- 
traction being perceived under the influence of the battery, and 
had told the parents that their child would be compelled to re- 
sort to mechanical means during the rest of her life. I felt 
justified in making this statement at the time, as I could obtain 
no response of the muscle myself, and as she had already been 
under the treatment of one of our best electricians for many 
months without any benefit. 

Taking these facts into consideration, as before said, I sent 
for the case, the history of which is as follows : 

Case. December 24, 1868. — Pauline K., aged five years and 
nine months, perfectly well until fifteen months old, when left 
foot was discovered to be paralyzed. Was treated at that time by 
Dr. Peter Van Buren. A few months later Dr. Henschel directed 
a shoe to be applied which she has worn ever since. Prof. 
Gross, about three years ago, proposed to cut the tendons, but 
it was not done. About two years since, Dr. Guleke applied 
electricity for nearly nine months, without any apparent benefit. 
She was then brought to me for treatment, and finding no re- 
sponse to the battery when applied to the gastrocnemius muscle, 
even when needles had been inserted in it, and satisfied that Dr. 
Guleke had given her all the benefit that electricity afforded, 
I stated to the parents that further treatment would be useless, 
and simply directed a shoe to be worn, with an artificial gastro- 
cnemius, as seen in Fig. 14. This was in the latter part of 1866. 

When she returned to me in December, 1868, her foot had 
increased somewhat in length and size, but the muscles of her 
leg were no better developed than when I saw her two years 
before, and as here represented in Fig. 15 (as drawn by Dr. Yale), 
unsupported by the shoe. 



40 



DEFORMITIES. 



"When she attempts to walk without the instrument, the 
weight of her body is supported on the extreme posterior part of 




Fig. 14. 



the os calcis. The foot could very readily be brought to its natu- 
ral position, in which place it was held during the application of 




Fig. 15. 



ACTION OF ELECTEICITY. 41 

the galvanic current, which was continued for half a minute or a 
minute. After the action of the battery one-eightieth of a grain 
of strychnine was injected into the gastrocnemius, and the shoe 
with the elastic force applied as before. 

The battery was applied in this way from half a minute to a 
minute at a time each day, for six weeks, before any perceptible 
contractions of the muscles could be observed. The injections of 
strychnine were repeated every eight or ten days for some three 
months. 

The improvement for the first six months was very slight in- 
deed, but still noticeable, and the time occupied in the application 
of the battery was increased to three or five minutes as the mus- 
cles became stronger ; but, even then, it was observed that after a 
few vigorous contractions the muscles would refuse to respond to 
the same power of the battery. 

May, 1870.— Very much improved ; begins to have voluntary 
power over the muscles. 

November, 1870. — Can make a forcible, voluntary contraction. 

May, 1872. — Can extend the foot almost to the normal posi- 
tion when sitting down, but incapable of walking without artifi- 
cial support. 

The muscles of the calf of the leg have increased very much 
in size, but exact measurements were neglected to be taken. 
She still continues to use the shoe with elastic gastrocnemius, as 
seen in Fig. 14. 



LECTURE VI. 



DEFORMITIES. 



Treatment (continued).— Manipulation.— Massage.— Dry Heat— Baths.— Inunction.— 
Gymnastics. — Medicinal Agents. 

Gextlemex: ~We will continue the study of the general 
principles which are to guide us in the treatment of deformi- 
ties, and to-day I will first invite your attention to manipulation. 

Manipulation may be regarded as the natural remedial agent 
for the cure of a deformity. In very many cases, so far as the 



42 DEFOEMITIES. 

cure is concerned, the operation is the most insignificant part of 
the treatment. " For example, in club-foot, tenotomy may be 
necessary ; but, gentlemen, it is the subsequent manipulation of 
the foot that is, in a very great measure, to effect a permanent 
and complete cure. 

Without manipulation, giving the foot a variety of passive 
movements, the result obtained by the operation, and fixing the 
foot in some immovable apparatus, is exactly what may be seen 
everywhere around us. Only a few months elapse before every- 
thing is as bad as it was previous to the operation, in conse- 
quence of the adhesions that have taken place. The importance 
of this principle we shall be able to demonstrate over and over 
again by cases which will be brought before you where its ob- 
servance has been neglected. 

Mechanical appliances are necessary, for the purpose of re- 
taining deformed parts in certain positions after they have been 
placed in such positions by manual force ; but the more frequent- 
ly these mechanical appliances are removed, and the part sub- 
jected to manipulation, the greater will be the success that will 
attend your treatment of this class of deformities. While using 
any mechanical apparatus if manipulation be neglected, your 
patient will be deprived of that stimulus, motion, which is so es- 
sential for the perfect preservation of the usefulness of the de- 
formed parts. 

There is a case in my mind at the present time, which was 
one of the most melancholy I have ever seen. The case is worthy 
of recital. It was one in which there was fully-developed disease 
of the hip-joint. The lad lived at a long distance from the city, 
and the gentleman who performed the operation of tenotomy 
did it in a skillful manner. The limbs were dressed in the or- 
dinary " w T ire-breeches," and the physician who had the case in 
charge was instructed with the greatest care concerning the ne- 
cessity of frequently removing the dressing, performing slight 
manipulations, and then replacing it. The case had been, for 
three or four years, one in which the patient had suffered the 
most intense agony, and had slept only under the influence of 
large doses of anodynes. As soon, however, as the patient was 
placed in the immovable apparatus, and properly extended, he 
was so perfectly comfortable and easy, and slept so well at night, 
that the doctor who had him in charge thought it unnecessary to 



NECESSITY OF MANIPULATION. 43 

remove it, fearing he might not be able to replace it, and make 
him as comfortable as he then was and had been since the ap- 
paratus was applied. He was, therefore, permitted to remain in 
the " wire-breeches " for nine months, simply because he was so 
free from pain. The result was that the disease was cured ; but 
Nature had, unfortunately, cured it by anchylosing not only the 
hip-joint, which had been the seat of disease, but the hip-joint 
upon the opposite side, as well as both knee-joints and both ankle- 
joints. In five joints, in which there was not a trace of disease 
previous to the operation, anchylosis had taken place within nine 
months, without any inflammatory action at all, and simply be- 
cause the doctor had neglected removing the fixed apparatus oc- 
casionally, and subjecting the parts to manipulation and move- 
ment. In making the frequent changes, therefore, in your ap- 
paratus, do not forget the manipulations, and also make the sev- 
eral movements which are natural to the joints. 

There can be no substitute for manipulation by the hiunan 
hand. There is an intelligent touch that admonishes you of the 
amount of resistance present, the amount of force required to 
overcome it, and when you should stop its exercise. You are 
able by this means to determine whether you are producing 
spasmodic contractions and consequent irritation, and you can 
arrest your force at any desired point. Under this head may also 
be embraced all that is understood by the fanciful term massage. 

The principle is excellent, but the name is quackish. The 
term simply means friction or shampooing applied to muscles to 
assist in restoring lost vitality. All such movements are exceed- 
ingly beneficial, and very much increase nutrition by stimulating 
an increased blood-supply to the parts ; the friction and kneading 
stimulate the absorbents in the removal of abnormal deposits. 
All such manipulations, however, of whatever name or nature, 
should not be continued so long, or used with so much force, as 
to excite inflammation, reflex contraction, or over-fatigue. Not- 
withstanding their great service and importance, an excess of 
them may produce irreparable injury. 

Dry Heat. — Much benefit may be derived from the use of 
this agent. It is especially adapted to the treatment of paralytic 
deformities, and is beneficial from the fact that it solicits more 
blood to the part to which it is applied. It may be applied by 
means of any apparatus which the ingenuity of the patient or sur- 



44 DEFORMITIES. 

geon may devise. A very convenient method is by means of 
ordinary clay tubing. This means has lately been suggested by 
Dr. G. M. Beard, of this city. Clay tubes may be cast of any 
shape desired, heated to any degree bearable, and then the limbs 
may be placed within them. 

Baths. — The bath is another item of general treatment, the 
value of which can hardly be over-estimated. The temperature 
is to be varied according to the constitution of the patient and 
the character of the deformity. In the treatment of paralytic de- 
formities the bath is one of the most useful adjuvants to other 
treatment that can be employed. In such affections it should 
always be warm, and should be continued for a long time. In- 
stead of being applied to the whole body, it should be applied 
to the part affected. In such cases the object of the bath is to 
increase the circulation of blood through the paralyzed parts for 
the purpose of increasing their nutrition. 

You all know very well that, if you place your finger in a 
vessel of hot water, it will increase in size by increasing the 
quantity of blood, sufficient to prevent the removal of your ring 
from it. If, now, you plunge the same finger thus swollen into a 
vessel containing ice-water, contraction will follow and diminish 
the quantity of blood in the finger, and it may be sufficient to 
permit the ring to fall off. In the same manner the quantity of 
blood circulating in a paralyzed limb can be materially increased 
by means of the localized warm bath, the other parts of the body 
being cold, and in this way constitutes an important adjunct in 
the treatment of paralytic deformities. 

Inunction. — You also have inunction as a means of general 
treatment. Upon this point I have but very little to say, for I am 
not very fond of grease. Oil — particularly petroleum — may be 
of benefit ; as a general rule, however, all greasy substances are 
of but little value in this connection. The common people all 
have great faith in ointments, liniments, and various kinds of oil 
for the cure of paralyzed limbs, contracted tendons, etc. They 
are, therefore, constantly recommending for use skunk' s-grease, 
chicken's-teeth grease, and many other specific greases ; but my 
belief is that the chief, and I may say the sole benefit arising 
from their employment, is due to the " elbow-grease, or palm- 
oil," which necessarily accompanies their use, and not to any vir- 
tue possessed by the grease employed, unless it be that the small 



MEDICINAL AGENTS. 45 

quantity of phosphorus sometimes found in the combination 
may be a source of benefit. 

A new article called cosmoline can now be obtained, which 
possesses most remarkable lubricating properties. This article is 
serviceable, from the fact that in very small quantities it lubri- 
cates the parts to such an extent, that friction may be kept up 
for a long time without producing undue irritation. 

Gymnastics. — These are of great service in the treatment of 
deformities, but they must be used with much caution and under 
wise supervision. The muscles should be made to perform an 
exceedingly small amount of labor at first, lest over-fatigue be 
produced. It must be constantly kept in mind that, in all these 
deformed members, there are feebleness of circulation and impov- 
erished muscular fibre, especially in the paralytic varieties. Con- 
sequently, a very small amount of movement may sometimes be 
very severe work for such muscles. 

These exercises should be regular, systematic, and progressive, 
if you would derive the greatest possible advantage from their 
use. 

Medicinal Agents. — There is a constitutional treatment which 
may be serviceable in many cases of disease which we shall have 
occasion to consider ; but I feel warranted in warning you at the 
very outset that constitutional treatment, in the ordinary accep- 
tation of that term, does not justly, in the vast majority of cases, 
occupy that prominent position which has hitherto been assigned 
to it. It will be seen hereafter, that many of those cases which 
have heretofore been regarded as the local manifestations of a 
constitutional cachexia are of purely local origin ; and, instead of 
requiring a prolonged course of general treatment to remove a 
constitutional cause, they require a local treatment to remove a 
localized source of irritation, and through this the constitutional 
disturbance. Such treatment, when instituted, will permit the 
natural powers of the system in a great measure to restore them- 
selves. 

The constitutional treatment which is usually most bene- 
ficial is that embraced in a general observance of the laws of 
health ; such as giving the patient an abundance of fresh air, a 
nourishing and easily-digested diet, and only such medicinal 
remedies as may be necessary to maintain a normal performance 
of the secretory and excretory functions. With regard to special 



46 DEFORMITIES. 

remedies to be administered in special cases, these will be fully 
considered when we come to speak of the treatment of separate 
diseases. Strychnia, however, is a remedy so constantly em- 
ployed in the treatment of paralyzed muscles, that a brief refer- 
ence should here be made to its use. It should be administered 
in doses sufficient only to produce slight twitchings of the muscle. 
The administration of g^-grain doses three times a day, and the 
subcutaneous injection of one-sixtieth of a grain into the muscle, 
once in eight or ten days, will ordinarily be sufficient to produce 
the desired results, and will also, as a rule, be of much service. 
Over-fatigue of muscles can be brought about by exciting undue 
contractions with this remedy, as well as by the application of 
electricity, or by excessive manipulation. Such fatigue is to be 
carefully avoided. 

Thus, gentlemen, I have given you a general outline of our 
subject. I have endeavored to lay before you the reasons why 
you should make it a special study ; I have directed your atten- 
tion to the different varieties of deformities you will meet with, 
and have mentioned the general principles which are to govern you 
in their treatment. And I have, also, in a general way directed 
your attention to the operative treatment, and the mechanical ap- 
pliances, etc., which are to be used subsequent to the operation. 
Repetitions of what has already been said will constantly be made 
throughout the entire course, and for so doing I have no apology 
to make, but on the contrary shall hope thereby to indelibly im- 
press the principles which I teach upon your minds. We are now 
ready to commence the study of special deformities, and at my 
next lecture we will begin the study of talipes. 



DEFINITION. 47 



LECTURE TIL 

TALIPES. 

Definition. Varieties and Combinations. — Mechanical Construction of the Normal 

Human Foot. — Talipes Equinus.— Talipes Calcaneus. — Case of Division of Tendo- 
Achilles by an Accident. — Mechanical Treatment of Talipes Calcaneus. 

Gentlemen : To-day we commence the study of special de- 
formities ; and that which will first engage our attention is com- 
monly known by the name of club-foot. The technical name for 
this class of deformities (for there are several varieties) is talipes. 

Under the term Talipes are included all deformities in which 
there is a permanent deviation from the normal relations of the 
foot to the leg, or of the parts composing the arch of the foot to 
each other, whether this deviation consists in flexion, extension, 
inversion, or eversion. Talipes is usually described under four 
distinct heads, namely, talipes equinus, talipes calcaneus, talipes 
varus, and talipes valgus. 

Typical examples of any of these varieties are rare, for, nearly 
always the deformity is a combination of two varieties. For ex- 
ample, equinus may be combined with varus or valgus, and the 
same is true of calcaneus. 

"When we wish to designate such a deformity, the names of 
the two component distortions are combined, the more important 
always being placed first. Thus when we have a combination of 
equinus and varus, it is styled equino-varus or varo-equinus, 
according as the equinus or varus is the more prominent, and the 
same principle of nomenclature is used for calcaneo-varus and 
valgus. 

In addition to the above-mentioned varieties, there is one 
known as talipes cavus or plantaris. This is a very frequent 
complication of other varieties of talipes. When it is present 
as a complication, it does not, as a rule, enter the name of the 
deformity. When, however, as occasionally happens, the case 
presents no other deformity than that caused by the contrac- 
tion of the plantar fascia, the name talipes cavus or plantaris is 
used. The deformity known as flat-foot, I think, should be con- 
sidered as a variety of valgus, as the peculiar breaking down of 



48 TALIPES. 

the arch is the same in both, and the two affections are very gen- 
erally associated. In order to have a correct understanding of 
our subject, it is necessary, before proceeding to the definition 
and description of the different varieties of club-foot, to turn our 
attention to the study of the mechanical construction of the nor- 
mal human foot. 

The human foot, in its natural state, is one of the most beau- 
tiful examples of a complicated machine, combining great strength 
with graceful mobility, that can be found in any part of the hu- 
man frame : consisting as it does of twelve bones (in addition 
to those of the toes), joined to each other by regularly-construct- 
ed articulations, admitting of motion to a greater or less degree 
of each individual bone — so that no restraint can be put upon 
these slight movements between the various bones without de- 
stroying the harmony of their combined action in the foot as a 
whole — and at the same time being so firmly bound together 
by ligaments, and sustained in position by tendons attached to 
strong muscles, as to give it an abundant security to bear the 
superincumbent weight of the body, while it allows of sufficient 
expansion and extension for ease and elasticity in locomotion. 
It is connected with the leg at the astragalo-tibial articulation, 
and prevented from any late?*al movement by the projecting mal- 
leoli on either side, which fit so closely to the sides of the astraga- 
lus as to permit of no motion at this joint, except that of flexion 
and extension, or that of pointing the toes up or down. Turning 
the toes out or in is produced by rotation of the thigh and leg at 
the hip-joint, or by the revolving motion of the fibula, produced 
by the contraction of the biceps and tensor vaginge fern oris, when 
the knee is flexed. 1 

1 Prof. S. D. Gross, after thanking me for a copy of my work on club-foot, which 
he states is " of great practical value to the profession," adds, in his letter : " I shall 
still continue to make lateral motion at my ankle-joint without rotating'my hip or re- 
volving the head of my fibula." So great a difference of opinion from such a distin- 
guished authority made me, of course, exceedingly uneasy to think that I had been 
such a careless observer, and I therefore dissected a number of feet, both of children 
and adults, making most careful ligamentous preparations of each, and, after the most 
critical examination of all these specimens, I was unable to produce the slightest later- 
al movement in any of them. I therefore feel perfectly justified in asserting' most 
positively the correctness of my first statement — that there is no lateral motion at the 
astragalo-tibial articulation. The lateral movement of the foot, which appears to take 
place at this joint, actually occurs at the junction of the os calcis with the astragalus, 
the latter bone being so firmly embraced by the external and internal malleolus as to 
permit of no lateral movement whatever. 



ANATOMY OF THE FOOT. 



49 



Having stated that no motion can occur at the tibio-tarsal or 
ankle joint, except flexion and extension, and that the pointing 
of the* toes out or in is done by the muscles of the hip, as above 
described, it follows, as a matter of course, that all the other mo- 
tions of the foot, such as twisting the sole inward or outward, 
raising or depressing the arch, etc., must occur between the joints 
of the other eleven bones of the foot. The toes, being merely 
attachments, are not considered as having any influence in these 
motions. 

If we carefully examine the foot, as seen in Fig. 16, we shall 
observe that, between the os calcis and astragalus behind, and 
the cuboid and scaphoid in front, is the medio-tarsal joint, a, 5, 




Fig. 16.— a, 5, the medio-tarsal articulation; c, the astragalus; d, the os calcis; «, the scaphoid; 
■» f, middle cuneiform ; g, external cuneiform ; /i, cuboid ; i, the metatarsal bones. 



going completely across the foot, dividing it into an anterior 
and posterior portion, admitting in a limited degree of every 
variety of motion — flexion, extension, abduction, and adduction, 
as well as rotation inward and outward upon the long axis of the 
foot. I desire to call particular attention to this compound artic- 
ulation in the tarsus, because, by a most remarkable oversight of 
surgeons, the very important part which it plays in deformities 
of the feet has until very recently been entirely unnoticed. 

The foot, as a means of support, rests upon three buttresses : 
the heel behind, which is stationary ; and the first and fifth meta- 
tarso-phalangeal articulations in front, which are slightly mov- 
able, capable both of expanding and extending, thereby increasing 
the base of support, which adds to the security of the body, and 
by this very expansion and extension of the anterior pillars, or 
buttresses, gives elasticity in locomotion. 

Between these three pillars, or points of base, spring two 
4 



50 



TALIPES. 



arches : one from the heel, reaching to the anterior two pillars, 
narrow behind, and wider in front, called the antero-posterior 
arch; and one from the two anterior pillars arching across the 
foot, called the transverse arch. The antero-posterior arch is 
higher on the inner than on the outer side, and cannot be brought 
to the ground in the normal condition of the foot, whereas the 
outer line of this arch is always brought to the ground whenever 
the weight of the body is borne upon it. 

Let any one dip his naked foot in a pail of water, and then ? 
while wet, stand with it upon a dry board or piece of brown pa- 
per, and he will get an exact impression of the parts of the foot 
which come in contact with the earth in supporting the weight 
of the body. (See Fig. 17.) It will be seen that the outer line 





Fig. 17. 



Fig. 18. 



of the arch touches its entire length, which thus gives it a firm 
and extensive base of support, whereas the inner line only touches 
the ground at its two extremities, the central part of the arch on 
the inner side being retained in position by the tibialis-anticus 
muscle, which is inserted into the inner and under surface of the 
internal cuneiform and base of the first metatarsal bones. It 
will, therefore, be seen that the strength and perfection of this 
arch are greatly dependent upon the condition of the anterior 
tibial muscle. The importance of understanding the construc- 
tion and retention of this arch will be more fully seen when we 
come to study the deformities of the foot, more particularly tali- 
pes valgus, or flat-foot. 

We are now prepared to go on with the study of the morbid 



TALIPES EQUINUS. 51 

alterations in the form of the foot, which are more numerous 
than those affecting any other part of the body. The first vari- 
ety to which I will direct your attention is that known by the 
name of talipes equinus. 

Talipes equinus receives its name from the position of the 
foot, simulating the hoof of. a horse. 

The deformity consists in the raising of the heel and drop- 
ping of the anterior portion of the foot, so that the weight of 
the body is borne upon the metatarso-phalangeal articulation 
alone, instead of upon the three points above spoken of. (See 
Fig. 18.) The convexity of the arch of the foot is generally very 
much increased ; and the concavity of the arch becomes more 
and more angular in proportion to the degree of the deformity. 
The toes are extended upon the foot, and the foot is extended 
upon the leg. Sometimes the foot is so much extended as to 
make almost a straight line with the tibia. This peculiarity in 
the deformity is usually associated with a paralyzed condition of 
the extensor muscles of the toes. Ordinarily, however, if these 
muscles possess the power of contraction, they voluntarily con- 
tract and elevate the toes sufficiently to enable the patient to 
walk upon the base of the metatarsal bone of the great-toe, as 
seen in Fig. 18. When the paralyzed condition referred to is 
present, there is absence of power for lifting the toes, which 
necessitates the use of crutches when the patient walks. 

Talipes equinus may be either congenital or acquired. The 
deformity much more frequently occurs under the form of equi- 
no- varus, or varo-equinus. These are also by far the most com- 
mon forms of deformities of the foot. The origin of these 
varieties is usually congenital. Again, talipes equinus may be 
paralytic or spastic ; or the spastic condition may be developed 
upon the paralytic. The latter condition may be developed by 
long-continued walking upon the deformed parts, thereby ex- 
citing inflammatory action, and when present will require te- 
notomy before a cure can be effected. If the deformity is 
purely paralytic, it can be overcome by the application of me- 
chanical means and elastic force, which shall take the place of 
the paralyzed muscles, until by the use of electricity, friction, 
strychnia, etc., they have been restored to the power of proper 
contraction. The paralytic variety is easily recognized, from the 
fact that the foot can be easily restored to its normal position ; 



52 



TALIPES. 



but, when the force which has restored it is removed, the deform- 
ity immediately returns. The muscles chiefly affected in the 
paralytic variety are those upon the anterior aspect of the leg. 
On the contrary, when the equinus is spastic, it is due to abnor- 
mal contraction of the muscles upon the posterior aspect of the 
leg. 

The next variety of deformity which we shall study is called 
talipes calcaneus. 

Talipes calcaneus is that variety of deformity where the 




Fig. 19. 



anterior portion of the foot is elevated, and the heel is depressed. 
(See Fig. 19.) 

This variety may also be congenital or acquired. It is fre- 
quently seen as a congenital deformity, and all the cases which 
have fallen under my observation have been of a paralytic 
nature. This deformity is much more liable to occur compli- 
cated with varus or valgus, than to present itself uncomplicated. 
When paralytic, the muscles chiefly affected are the gastrocnemius 
and soleus ; and in the treatment to be adopted the application 
of artificial muscles to take the place of the paralyzed gastro- 
cnemius and soleus forms an essential element. 

Talipes calcaneus is very often acquired. It may result from 
jumping, wrestling, or the application of any force sufficient to 



REMOVAL OF CICATRICES. 53 

rupture or cut the ten do- A chillis. It occurs again as the result 
of injuries received upon the anterior portion of the foot. A 
very common cause in this connection is the cicatricial con- 
traction following burns. The gradual contraction of the cica- 
tricial tissue overcomes the action of the gastrocnemius and soleus 
muscles, and, as a consequence, the anterior portion of the foot 
becomes elevated and the heel depressed. In all such cases, 
therefore, it is an exceedingly important point in their manage- 
ment to prevent this contraction during cicatrization, and thus 
prevent the deformity. It is important to keep the foot as 
forcibly extended as possible. By this measure, as a matter of 
course, you materially delay the cicatrization, but you promote 
the ultimate usefulness of the limb very essentially. 

Extend the ulcerated surface as far as you can, and let it heal 
as slowly as possible. This is one method of management, and 
the one ordinarily employed, until another step had been taken. 
By the old method cicatrization was allowed to go on from cir- 
cumference to centre until the whole granulating surface had 
been closed in, which was usually an exceedingly tedious process. 
Now the surgeon transplants a number of little islands of skin 
to the granulating surface, and from each of these little islands 
new skin grows and spreads, and you heal the wound by cicatri- 
zation as before ; but it is from the new blood-vessels formed, 
giving us a far different cicatrix from that obtained by the process 
of granulation. The cicatrix is much more yielding, is softer, 
and less liable to contract. The same principle is applicable in 
the treatment of extensive burns about any of the joints, or in- 
volving the palmar fascia. 

A case, however, may come to you for treatment in which 
very great contraction has already taken place. The question 
arises, Shall we undertake to correct such a deformity % In 
many cases the deformity will be so great, and the destruction of 
tissues so extensive, that nothing can be done. If, however, you 
should judge that an operation would be justifiable, never simply 
cut across the adhesive bands, for no permanent benefit will fol- 
low your operation. You must dissect away the entire cicatrix, 
and then bring the foot into its normal position, and retain it 
there, leaving the wound open. As soon as granulations have 
made their appearance, and the wound has taken on a healthy 
condition, transplanting may be resorted to for the purpose of 



54 TALIPES. 

hastening and improving cicatrization. If you succeed in restor- 
ing the deformed parts to their normal position, some artificial 
apparatus must be applied, and the application must be kept up 
until the patient can voluntarily flex and extend the foot in the 
normal manner. 

Prevention of deformity is therefore an essential part in the 
management of all injuries affecting the anterior portion of the 
foot, but especially burns. When the tendo-Achillis becomes rup- 
tured from any cause, or is accidentally cut, the foot should be 
dressed in the position of talipes equinus, and the leg flexed upon 
the thigh. This position is to be maintained until the tendon is 
fully healed, when passive movements should be resorted to for 
the purpose of bringing the foot into its normal position. 

The following case, treated by Dr. Yale, is a beautiful illus- 
tration of the success that may be obtained by proper treatment : 

Case. Wound of Ankle, dividing the Tendo-Achillis / Re- 
covery, with Perfect Use of Foot. — " Mr. K., aged about twenty- 
eight, September 1, 1872, stood on a chair, and placed his right 
foot in a stationary wash-basin to bathe it. His weight being 
great, about two hundred pounds, the bottom of the basin, already 
cracked, gave way, and the foot and part of the leg passed through 
the hole thus made. This occurred about 8 a. m. He was seen 
soon after the accident by one or two medical men, who did not, 
however, permanently dress the wound. At 11 a. m., three hours 
after the accident, I saw the patient. The haemorrhage had been 
quite profuse but apparently venous, and had then ceased. The 
line of the incision was transverse directly above the os calcis, its 
direction was forward and upward, and was an inch and a half 
deep. The tendo-Achillis was cut off near its insertion, and its 
short stump was plainly visible. The posterior tibial artery could 
be seen beating under a thin covering of connective tissue. The 
joint apparently was not opened. The cut reached on the outer 
side to the posterior margin of the external malleolus, on the 
inner side to the anterior surface of the internal malleolus. The 
anterior, one and a half or two inches, was probably burst rather 
than cut. From the anterior extremity of the line a V-shaped 
piece of integument, with its apex at the malleolus, was torn up, 
the anterior line being about five inches long ; the posterior curv-- 
ing around, behind the calf, seven or eight inches. The flap be- 
hind was also everted. 



DIVISION OF TENDO-ACHILLIS. 55 

" From the wound I cleaned out a number of small chips of 
the broken porcelain basin, and also some clots. The V was 
carefully stitched into place. The upper part of the tendo-Achil- 
lis was retracted out of sight, and could not be reached. The 
surfaces of the wound were approximated as accurately as possible, 
and stitched, a vent for drainage being left on the outside of the 
stump of the tendo-Achillis. Adhesive plaster, compresses, and 
bandages, were applied. To keep the foot in a proper position, 
a thin board was fastened to the sole of the foot, the knee was 
flexed, the foot extended on the leg, the limb laid upon its outer 
aspect, and the posterior extremity of the sole-board drawn up- 
ward by a cord toward some turns of bandage encircling the 
lower part of the thigh. This retained the limb in the position 
best calculated to approximate the separated ends of the tendo- 
Achillis. 

" At night it was necessary to nick the bandage around the 
wound, to accommodate it to the swelling, and to give an opiate. 

" The after-history contains no points of especial interest. 
There were no bad symptoms. The patient suffered from sleep- 
lessness for a few nights. The wound healed quickly, except 
just near the tendo-Achillis, where, after the first closing, pus to 
the amount of a half drachm or thereabouts collected several 
times and required a small incision to evacuate it. The limb was 
kept in the position above described most of the time for five or 
six weeks, until the wound seemed securely healed. 

" At the end of two months the patient began to go to his busi- 
ness. At first he wore a shoe with an upright support jointed 
opposite the ankle, and an elastic band behind to supplement the 
action of the gastrocnemius and relieve that muscle from too great 
strain. This was discontinued as soon as the disappearance of 
ice from the streets rendered walking safe. 

"April 3, 1873. — Has had perfect control of the articulation 
for some time, and wears no artificial support whatever." 

The mechanical apparatus used in the treatment of talipes cal- 
caneus differs somewhat in its construction from that commonly 
employed in the treatment of the other varieties of talipes, and 
can be better described here than under the head of general treat- 
ment. The objects to be gained are elevation of the heel, and a 
corresponding depression of the anterior portion of the foot ; con- 
sequently, your apparatus must be constructed in a manner to 



56 TALIPES. 

meet these indications. With these objects in view you may 
construct an apparatus in the following manner : 

Take a thin piece of board, a piece of cigar-box or thin shin- 
gle, a little longer than the child's foot, cover it with adhesive 
plaster, and fasten it to the sole of the foot, allowing the board 
to project somewhat behind the heel. When fastened to the an- 
terior portion of the foot, bring the foot into position, and then 
carry the long piece of adhesive plaster attached to the posterior 
extremity of the board up along the posterior aspect of the leg, 
and there secure it by means of a roller-bandage. Such an appa- 
ratus should be constantly worn until the child is old enough to 
walk, when a shoe will be required. For this purpose an ordi- 
nary shoe may be used, having a steel sole. From the heel, pro- 
jecting a trifle behind like a spur, is an eylet. Two upright bars 
are attached to the sole of the shoe, one upon either side, having 
a joint opposite the ankle-joint. These bars terminate in a band 
which goes around the upper portion of the leg. At the poste- 
rior portion of this band an artificial muscle is attached and ex- 
tends to the eylet before mentioned. (See Fig. 20.) 




One or more artificial muscles are to be used, according to the 
amount of traction required, and are to take the place of the 
paralyzed muscles until they are able to perform their functions 
without artificial aid. 

The after-treatment of talipes calcaneus is to be conducted upon 
the same plan as the other forms of talipes. This will be fully 
considered when we come to the subject of general treatment. 



TALIPES VARUS. 



57 



LECTURE YIII. 

TALIPES. 

Talipes Varus.— Causes of. — Case.— Complications. — Case. — Talipes Valgus. — Causes 
of. Paralytic Variety, with Cases. — Treatment of the same. 

Gentlemen : At the close of my last lecture I was speaking 
to you upon the mechanical treatment of talipes calcaneus ; to- 
day I invite your attention to another variety of talipes which 
has received the name of talipes varus. 

Talipes varus is that variety in which the foot is inverted, 
and more or less rotated, in such a manner as to bring its inner 
surface upward, and the outer edge to a greater or less degree 
upon the ground. (See Fig. 21.) 




Fig. 21. 



The muscles chiefly affected in the paralytic variety are the 
peroneals. 

This variety of talipes may be congenital, and, when combined 
with equinus, usually is of such origin. Complicated with equinus, 
it is one of the most common forms of deformity of the foot. 
Indeed, uncomplicated talipes varus is exceeding rare. 

When congenital it is usually of a paralytic nature, but it 
may be spastic, as the result of some influence exerted upon the 
foetus. When the deformity is acquired, it is also most frequent- 
ly of a paralytic nature. The most common cause, probably, is 
that form of paralysis known as " infantile." The child may go 



58 TALIPES. 

to bed apparently in perfect health, and awake in the morning 
with the lower extremities paralyzed ; or the child may have 
convulsions in consequence of some peripheral irritation, such 
as teething, the presence of some irritating substance in the in- 
testines, etc., etc., and these may be followed by paralysis which 
perhaps may affect all four extremities. Gradual restoration may 
go on until perfect motion is restored to some of the parts in- 
volved, but there still remains a paralysis of certain muscles or 
groups of muscles, and consequently, motion is lost and defor- 
mity developed. 

Case. Talipes Varo-Equinus Paralytica, relieved by Elastic 
Tension. — Catharine 1ST., aged four years, !No. 16 Washington 
Street. The mother states that the child, when two years of age, 
went to bed in perfect health. In the morning both lower ex- 
tremities were completely paralyzed. The probable cause was an 
apoplectic effusion into the lower portion of the spinal cord. 

After a few weeks she began to move the right limb a little 
when it was tickled or pinched ; these movements gradually in- 
creased until she had recovered perfect motion of that side. The 
left leg remained paralyzed on the outer side, causing a severe 
form of varo-equinus, as seen in Fig. 22. When her weight was 




Fig 22. 



put upon it the varus was very much increased, the foot making 
almost a complete rotation at the medio-tarsal articulation. 

The limb was very much wasted, blue and cold. The peronei 
muscles would not contract under a strong Kidder's battery. 

On the 16th of August, 1867, I applied the India-rubber 
muscles over the tibialis anticus and peronei muscles in order to 
elevate and evert the foot. The muscle was applied with only a 
moderate degree of tension, but in less than half an hour it had 
produced a marked change in the form and position of the foot. 



CASE OF TALIPES VARUS. 



59 



The chain was shortened a few links, and in three hours she could 
stand upon her foot, touching the ground both with the heel and 



great-toe, as in Fig. 23. 





Fig. 24. 



Electricity was applied in this case to the outer and anterior 
portions of the leg from ten to fifteen minutes every other clay, 
and the child encouraged to run around as much as possible. The 
plasters and tin had to be readjusted occasionally ; but at the end 
of eight months she had so far recovered as to require only the 
slightest elastic, hooked into the eyelet of an ordinary shoe, and 
attached above to her garter. AYith this slight force she could 
elevate the toes and walk perfectly naturally, as seen in Fig. 2i. 

Again, talipes varus may be developed by blows or other in- 
juries to the muscles, by which their nervous supply is impaired, 
and loss of power caused. 

In this connection I present a case which is worthy of your 
especial attention. It is one of varo-equinus. The foot, as you 
see, is strongly inverted, the heel elevated and very much dimin- 
ished in size, and upon the outer side of the foot are large callosi- 
ties which have resulted from walking upon it in this abnormal 
position. Again you will notice that the little toe of the affected 
foot is very much larger than that upon the sound one. It has been 
irritated and tormented by the almost constant pressure made upon 
it, thereby keeping up an excessive amount of circulation, and gen- 
uine hypertrophy has resulted. (See Figs. 25 and 26.) Here, then, 
we have a practical illustration of the same law I shall so often 
lay down to you, that constant manipulation, friction, shampooing, 



60 



TALIPES. 



electricity, etc., are of the utmost service in an attempt to restore 
muscular power, for the reason that they serve to increase the 
amount of circulation through the parts to which they are applied. 




Fig. 25. 



This foot is not at present in a condition to be cut, for the 
reason that these callosities are inflamed. This is a point to be 





Ftg. 26. 



Fig. 27. 



taken into consideration in the treatment of all varieties of de- 
formity. This foot should not be walked upon for several days, 



TALIPES VALGUS. 61 

and these callosities should have cold-water dressings applied to 
them until all inflammatory action has subsided. 

[The case was subsequently operated upon, and section made 
of the tendo-Achillis and plantar fascia. The first dressing applied 
was the ordinary board and adhesive plaster apparatus illustrated 
in Fig. 43. The Barwell apparatus, Fig. 37, was subsequently 
used, and the appearance of the foot when cured is illustrated 
in Fig. 27.] 

Talipes valgus presents the converse of talipes varus, the in- 
ner border of the foot being downward. (See Fig. 28.) 




Fig. 28. 



This deformity is much more likely to arise from traumatic 
causes than any other deformity of the foot. It frequently re- 
sults from inflammation of the ankle-joint. It may result from 
a pull or wrench of the foot, causing inflammation of the pero- 
nei muscles and subsequent spastic contraction. 

Talipes valgus may be combined with equinus or calcaneus, 
making valgo-equinus, or valgo-calcaneus. 

In some cases this deformity is of a purely paralytic origin. 
This cause being unappreciated, the projecting bones which make 
their appearance at the front portion of the foot are very liable 
to be mistaken for " diseased bones," " periosteal inflammation 
dependent upon scrofula," etc., and are treated accordingly. 
These cases I regard as worthy of special consideration, and shall 
dwell upon them sufficiently, I trust, to make them perfectly 
clear. In the severer cases the deformity is so conspicuous as to 
be readily recognized, but the less marked cases are very liable 
to be overlooked. 

In the majority of cases this kind of trouble occurs in persons 
who are obliged to stand or walk for many hours in succession, 



62 TALIPES. 

thereby giving constant exercise and strain to the tibialis-anticus 
muscle, which 'supports the arch of the foot. Finally, from over- 
work this muscle becomes partially paralyzed, the arch of the 
foot settles, and valgus begins to be developed ; and, as it in- 
creases in consequence of the loss of the arch of the foot, the 
head of the scaphoid bone begins to project, undue pressure is 
produced on a part of the foot not intended by Nature to receive 
it, and inflammatory action is excited, which. affects the scaphoid 
on the inner border, and also the articulations between the two 
cuneiform, cuboid, and the fourth and fifth metatarsal bones, and 
gives the patient the most exquisite and torturing pain. 

When the arch of the foot is properly supported by a healthy 
tibialis-anticus muscle, the articulating facets of the bones com- 
posing it press upon each other, so as to sustain the weight of the 
body without producing pain. These articular cartilages having 
no blood-vessels or nerves of their own, are insensible to pressure ; 
but, when the arch of the foot loses its proper support in conse- 
quence of a complete or partial paralysis affecting the tibialis- 
anticus muscle, these articulating facets no longer press upon each 
other equally, but are made to tilt a little, and the pressure is 
brought to bear upon the edges of the articular surfaces, where 
the supply of blood-vessels and nerves is most abundant, which 
gives rise to indescribable pain and suffering with every step 
that is taken. 

The pathology of these cases is, first, paralysis of the anterior 
tibial muscle ; second, settling of the arch of the foot ; third, 
abnormal pressure upon the edges of the cuneiform and scaphoid 
bones. 

The pressure in this abnormal position produces periosteal, it 
may be osteal, or synovial inflammation, and then it is that the 
case is so often regarded as one dependent upon constitutional 
disease. 

Now, having arrived at the true pathology, let us study their 
symptoms. The paralysis of the tibialis-anticus muscle can be 
detected by its wasted and flabby condition when compared with 
the same muscle upon the sound leg, or with a normal muscle 
when both the anticus muscles are affected. The spine of the 
tibia will be much more prominent than normal, the foot will be 
slightly abducted, and any increase of the abduction, either by 
traction or by bringing the weight of the body to bear upon it, 



PARALYTIC TALIPES VALGUS. 63 

causes pain at the points heretofore mentioned. Pressure with 
the thumb over the borders of the articulating surfaces of the 
cuneiform and scaphoid bones, when in the abnormal position, 
produces extreme pain ; but when the pressure upon these bor- 
ders is removed, which may be done by rotating the foot inward 
and raising the arch, the foot will be able to bear the weight of 
the body without producing pain. Usually, there is but very 
slight deformity in these cases, hence they require the manipula- 
tion indicated in order to detect the precise nature of the difficulty. 

The following case, which I saw in consultation with the 
late Dr. Krackowizer, is a very good illustration of the disease 
or deformity of which we are now speaking : 

Case.— On the 28th of December, 1872, 1 was requested by Dr. 
Krackowizer to see in consultation with him Mr. H., of Thirty- 
ninth Street, New York, as he had been lame more or less for the 
past three years. As the patient had been singularly affected, 
and as all the treatment which he had adopted had not relieved 
him, the doctor was anxious to have me examine the case. 

I found Mr. H., a young man of about twenty-five, in ap- 
parently perfect health, rather muscular in development, and 
able to walk around the room at that time with very little dis- 
comfort. The doctor stated that this had been his condition 
for the last three years whenever he remained quiet in his house 
for a number of clays together, but very moderate exercise for 
one or two days would cause him to complain of great pain over 
the inner border of the scaphoid, and in a narrow line on the top 
and outer side of the foot, which corresponded precisely with the 
junction of the second, third, and fourth metatarsal, with the 
middle and external cuneiform and cuboid bones. Any attempt 
to bear the weight of his body upon this single foot very greatly 
aggravated the pain in these situations. He had been frequently 
blistered over these points, but at the time of our visit they were 
painted with iodine. The doctor stated that at first, looking 
upon it as a rheumatic affection, he had treated it accordingly, 
and the patient had recovered ; but, finding that exercise al- 
ways caused it to return, he had suspicions of his diagnosis be- 
ing correct, and was unable to satisfactorily explain the case. 
There was no evidence of specific taint or he would have sus- 
pected that as its origin ; but the man had never been affected 
with syphilis, and the doctor, to make assurance doubly sure, had 



6i TALIPES. 

several times treated liim with iodide of potassium, and each time 
he would recover from the pain, but he was disposed to attribute 
his freedom from pain to the rest he secured during the time he 
was confined to his room and not to the medicine. 

The history of the case was as follows : Three years previous, 
when crossing the ferry to Astoria, one of the horses suddenly 
became alarmed when going on the boat, and he jumped from 
the wagon, used considerable exertion to get his horses on the 
boat, and finally was compelled to jump or spring very forcibly 
to get on the boat himself. Before he had crossed the river he 
began to feel a slight pain on the outside of his shin-bone, and 
when he arrived at Astoria found himself quite lame, but not 
sufficiently so to call in a physician. In a few weeks this all 
passed off, and he never complained of pain along his shin-bone 
or leg from that time, but after some months began to complain 
of pain at the inner border of the scaphoid, and at the junction 
of the two cuneiform and cuboid bones wdth the metatarsus, as 
before described. Upon a very careful examination of his two 
legs, the foot upon the right side was found to be a distinct 
valgus, and upon the outer side of the spine of the tibia there 
was a deep sulcus in which the finger could be readily placed, 
indicating that the tibialis-anticus muscle had probably been 
partially ruptured at the time of the accident. The diameters of 
the two legs at this point showed an inch and an eighth difference. 
The peroneals on the right side were very rigidly contracted, 
and could not be extended so as to allow the foot to be brought 
around to its normal position. 

The diagnosis was, therefore, rupture or paralysis of the 
tibialis-anticus muscle, eversion, abduction, and flattening of the 
foot. In consequence of this loss of the support to the arch, 
pressure upon these abnormal parts occasioned the intense pain at 
the points previously described, and the reflex contraction from 
this pain produced the spasmodic contraction of the peroneals. 

Dr. Krackowizer was so charmed with the diagnosis that he 
requested me to take charge of the case, allowing him the privi- 
lege of seeing it from time to time. 

I dressed him with the Barwell dressing, as seen in Fig. 37, 
placing a tin on the outer side of the leg, and connecting its top 
with an eyelet secured to adhesive plaster on the inner border 
of the foot by India-rubber elastics, so that by their contraction 



POINT-PRESSUEE. 65 

they took the place of the tibialis-anticus muscle. The relief to 
the pain was instantaneous upon the application of this elastic 
force, and the patient was able to walk about with great comfort. 
The cure, however, was not perfect until section had been made 
of the contractured peroneal muscles, which was done by Dr. 
Krackowizer at my suggestion in the following March. 

When I first saw this patient I was not aware of the princi- 
ple which I have since established, viz., that point-pressure upon 
a contractured tendon, producing reflex spasm, is an indication of 
the necessity of section, or we should have divided these muscles 
before any other treatment was adopted. Finding that I had 
simply gained relief from pain without making any improvement 
in the position of his foot when the elastic force was removed, I 
then examined him, and discovered that pressure upon the con- 
tracted peroneals produced a reflex spasm. Dr. Krackowizer sub- 
cutaneously divided them, as before mentioned, when the foot was 
immediately brought with ease into its normal position and re- 
tained there by adhesive plaster and a roller. The wound healed 
in a very few days, and at the end of a month, with a slight elas- 
tic to take the place of the tibialis, he was enabled to walk and ex- 
ercise as well as he ever did, and is able to do so to this day, sim- 
ply using a steel sole with an elevated arch to support his foot. 

I have seen many cases, of which the one just reported is a speci- 
men, but will only narrate one or two, for still further illustration. 

Case. — Some years since a gentleman called on me with his 
little boy, who, he stated, had been suffering for several years 
with scrofulous disease of the bones of his foot. He had applied 
to various physicians and had used all the constitutional remedies, 
as well as local means, for its relief without benefit, and wished 
me to examine it. I found an open sore about an inch in cir- 
cumference over the junction of the cuboid and two cuneiform 
bones with the metatarsal bones, which was kept discharging by 
some ointment which was daily applied. The peroneal muscles 
were very rigidly contracted ; the foot was a splendid specimen 
of valgus / the sulcus at the side of the tibia was very distinct, 
in contrast with the plump condition of the other leg ; there were 
an enlargement and projection of the scaphoid bone, the skin 
over which was covered with the tincture of iodine. As I was 
going to my lecture at that moment, and as I was lecturing upon 
club-foot at the time, I asked the gentleman if he would be kind 
5 



66 TALIPES. 

enough to get into the carriage and let me take the boy before 
the class. He stated that, as my explanation was the first clear 
one he had ever had in regard to the boy's condition, if it would 
be of any benefit to science, he would go with me most cheer- 
fully. I took him to Bellevue Hospital Medical College and 
subcutaneously divided the peroneal muscles. The foot was then 
restored to its natural position, and secured there by a strip of 
adhesive plaster passed around the foot, and carried up the inside 
of the leg, the plaster being secured by a well-adjusted roller, 
care having been taken to put a cotton pad on either side of the 
inflamed scaphoid where the adhesive plaster passed over this 
bone. I then ordered him a shoe to be made with an elevated 
inside steel sole, so as to support the arch of the foot ; an iron 
rod, running under the sole, came up on the inner side of the 
ankle, where it had a joint ; from this point a steel spring long 
enough to reach above the calf, terminating in a band to go 
around the leg. When this steel was bent outward, and secured 
to the calf of the leg, it necessarily bent the foot inward, and the 
steel sole in the bottom of the shoe sustained the bones of the 
foot in such manner as to allow them to receive pressure in their 
normal position, and gave perfect relief from pain. 

One week from the day of the operation, this gentleman 
again brought his boy with the shoe to my lecture at the college. 
The adhesive plaster was removed ; the wound occasioned by the 
tenotomy had firmly united. The sore upon the top of the 
foot not having entirely healed, a greased rag was put upon it ; 
his stocking and shoe having been put on, and the spring around 
the calf properly adjusted, the boy immediately walked around 
the room with perfect ease. 

Case. Double Talipes Valgus, or Flat-foot, from Weakened 
Anterior Tibials, mistaken and treated for Rheumatic Gout ; 
cured ly Artificial Forces to take the Place of the Weakened 
Muscles.— Mr. M., aged thirty-two ; a very large and heavy man, 
weighing two hundred and forty pounds ; proprietor of a public 
saloon. He had been for some years afflicted with great pain in 
his feet, upon taking the slightest exercise, more particularly 
when standing behind his bar. Being a free-liver, it had been sup- 
posed that he had rheumatic gout, and had been treated according- 
ly. Finding no permanent relief, except in the horizontal posture, 
he changed his medical adviser, and his new attendant, suspecting 



DOUBLE TALIPES VALGUS. 67 

there might be a syphilitic taint in the disease, placed him upon 
a liberal use of potassium and iron, in addition to the colchicum, 
the use of which he was directed to continue. By a few weeks' 
confinement to his bed, he would invariably get relief from the 
pain in his feet, but his stomach and other digestive organs had 
become so impaired by the constant use of colchicum and potas- 
sium, that after some years of treatment he abandoned all medi- 
cal advice, and simply resorted to his bed when his painful attack 
came on, and discovered that he recovered about as quickly by 
rest alone as he had before through medical treatment, and, at the 
same time, his digestive organs were much improved ; but one or 
two days' standing behind his bar would invariably compel him 
to keep to his bed the three or four succeeding days. 

In this condition, and with this history, he came under my 
care. Upon his naked feet he walked in the most awkward 
manner, his feet being very much everted, and the arch com- 
pletely broken down. Pressure over the junction of the cuboid, 
external, and middle cuneiform bones with the three median 
metatarsals, and over the lower and inner border of the scaphoid, 
gave intense pain. The tibial muscles on either side were very 
deficient in development, and he had no power of inverting or 
elevating the inner border of his foot. 

In this case, I injected strychnia (one sixtieth of a grain) into 
the tibial muscles, and repeated it every twelve days, and applied 
the Barwell dressing to both feet, in such a manner as to take the 
place of the deficient tibial muscles, and the following day he re- 
sumed his avocation of waiting upon customers at his bar. Elec- 
tricity was applied to the tibial muscles, every other day, for 
about three months, during which time he constantly wore the 
Barwell dressing. After this period, steel soles, made to fit the 
arch of the foot, so as to sustain them in the natural position, 
were worn in either shoe, and from that time to the present, 
over five years, he has remained in perfect health and attends to 
his business, never having an attack of rheumatism, gout, or any 
of his former suspected maladies. 

On reviewing my note-book, I find more than a score of cases 
almost identical with the three just described, but I will only 
quote one more. 

Case. — "Mr. M. D. F., aged about fifty years, a very large 
and heavy man, civil engineer by profession, was brought to me 



68 TALIPES. 

in the fall of 1857, from Halifax, to see if it were possible to have 
an operation performed upon his feet that might relieve him from 
his intense agony, and render him capable of following his profes- 
sion, or else to have his feet amputated at the ankle-joint, as stand- 
ing for any length of time, or locomotion, had become almost im- 
possible. During the last three years he had been confined either 
to his tents on the island of Newfoundland, and various places 
where he had been engaged in placing the telegraph-wire from 
Port Aubasque to St. John's, or else in St. John's, or Halifax, 
to which places he had been carried several times for treatment. 

" In all his confinements he had been supposed to have had 
rheumatism, gout, or a complication of the two, and had been 
treated for these diseases according to the best lights of science. 
He then resorted to all the various specifics that are adver- 
tised for the cure of gout, such as Blair's pills, White's pills, La- 
ville's specific, Reynolds's specific, and all the other remedies that 
promise to cure the gout, but all without any result except to 
greatly injure his digestive organs. His attacks recently had be- 
come so much more frequent and severe, that he was compelled 
at last to abandon the work, another engineer taking his place. 
He had formerly been an exceedingly active man — a great ath- 
lete — scorning the idea of fatigue or over-exertion, and during 
the first two years of his work on the island of Newfoundland 
had walked several times from Port Aubasque to St. John's, 
leaping creeks, climbing crags, and descending cliffs, until at last 
his muscles had become over-fatigued. The tibials having be- 
come wasted in tone, fiat-feet resulted, and, when the weight of 
the body was placed upon them, pressure was brought to bear 
upon the upper border of the edge of the junction of the cuboid 
external and middle cuneiform with the upper edge of the artic- 
ulating facets of the corresponding metatarsal bones of each 
foot. The under and inner surface of either scaphoid was also 
exquisitely sensitive, like an attack of acute periostitis, a perfect 
counterpart of the other case already described. 

" I asked him to walk into my inner office. This he started to 
do upon his crutches, and, as he reached the doorway, I stopped 
him and asked him to place each of his feet over the sill of the 
door (which happened to be about the proper height to sustain 
the arches of his feet), and, after some persuasion, induced him to 
lay aside his crutches and see if he could bear his weight upon 



DOUBLE TALIPES VALGUS. 69 

his feet in that position. He at first hesitated to make the at- 
tempt, but, being assured that I would not let him fall, he handed 
me his crutches, and stood erect upon his feet and instantly burst 
into tears, telling his brother who was with him, that from this 
they might think his disease and the agony he suffered was all 
pretense, but it was not so, and he could not understand how it 
was possible that resting only three days on the ship this time 
had cured him perfectly, for he was just as bad when he left 
Halifax as he had ever been in any of his numerous attacks, and 
now he felt no pain whatever. He was not aware that the sup- 
port to the arches of his feet had anything to do with his relief, 
and was very urgent in trying to persuade his brother that he had 
not been playing this game in order to be relieved from labor in 
that distant country, but that his disease was real. I gave him 
his crutches, and asked him to step off from the sill of the door 
and stand upon the even surface of the floor without any support 
to the arches of his feet, when he screamed out, in the most in- 
tense agony, " There is that old pain back again ! " 

" I took two pieces of sole-leather, and, marking them to fit his 
feet, cut out a pair of soles. These were dipped in cold water 
until they were perfectly soft, and then carefully moulded to the 
bottom of his feet and secured by a nicely-adjusted roller. The 
feet were then pressed into their natural shape, the leather firmly 
pressed up under the arch of each, and the feet held in this posi- 
tion for some time, until the leather had accurately assumed the 
shape of the bottom of his feet. He was then permitted to go 
home. From these leather models Messrs. Otto & Eeynclers,- of 
Chatham Street, constructed steel soles exactly similar and in- 
serted them into well-fitting boots, securing them at the heel by a 
rivet or screw. 

"Some days after Mr. Eeynders informed me that the boots 
were done, and had been sent to the brother's house in this city. 
I called there, on my way to the hospital, to see him, and to my 
amazement found that he had put them on and was coming 
down-stairs with his carpet-bag in hand, and going to the depot, 
Fourth Avenue and Twenty-seventh Street, to leave for his home 
in Massachusetts. By the use of this artificial support he has 
been entirely relieved from his gout, rheumatism, and rheumatic 
gout, without the employment of any internal remedy." 

The muscle chiefly concerned in this paralytic variety is the 



TO 



TALIPES. 



tibialis anticus, which fails to sustain the arch of the foot. There 
are various methods of relieving this particular class of cases, but 
the following are among the most serviceable : In the first place, 
a steel spring may be constructed of the exact shape of the arch 
of the foot in its normal position. Such a spring may be placed 
in a shoe and fastened at the heel, leaving the anterior portion 
free to move as the weight of the body is thrown upon it. A 
pattern for the spring can be obtained by making a plaster cast 
of the foot with its arch elevated to the normal position, and 
afterward the steel can be easily fitted to such a model. A shoe 
and spring arranged in this way will give support to the arch of 
the foot, but before permanent relief can be obtained vitality 
must be restored to the paralyzed anterior tibial muscle. Mr. 
Reynders, the instrument-maker, has made an ingenious contriv- 
ance which is very useful in this class of deformities, which con- 
sists of an upright bar on either side of the leg, with joints 
at the ankle, and secured to the sole of the shoe. These up- 
rights extend nearly to the head of the tibia, secured by a band 
behind and buckle in front. From the top of these bars a web- 




Fig. 29 



bing passes down inside the boot under the arch of the foot, the 
inner webbing having a few inches of elastic insertion. This 
webbing can be made taut or loose at the top of the bars by a 
buckle, so that the arch of the foot is sustained when stepping by 
the extra support given it by this piece of webbing. {See Fig. 29.) 



APPLICATION OF DRESSING. 71 

Another method of treatment is to attach to the inner side of 
the sole of the shoe an upright strip of spring-steel, having a 
joint opposite the ankle-joint and diverging from the side of the 
leg with a considerable angle. "When the foot is secured in such 
a shoe, the spring is brought in contact with the tibial side of the 
leg, and then secured. The action of the spring is to adduct the 
foot and give additional support to the arch. 

The most convenient method of treatment, however, and one 
equally serviceable, is that by means of the elastic tension which 
is afforded by Bar well's apparatus. This apparatus will be fully 
described when we come to the subject of treatment of talipes, 
and it is, therefore, only necessary to say here that you simply 
have to reverse this apparatus as applied for varus, to make it ap- 
plicable to the treatment of valgus. (See Fig. 37.) 

The apparatus must be made proportionately strong, according 
to the weight of the patient. 

There are a few points with regard to the application of the 
dressing which deserve special mention. One of the points of 
tenderness may be over the articulation of the scaphoid with the 
internal cuneiform bone, which is exactly in the line of traction 
made by the chain to which the artificial muscle is attached. The 
precaution should, therefore, be taken to pad around this inflamed 
point, by means of adhesive plaster and cotton, applied one strip 
upon another, until a sufficient thickness is obtained to prevent 
the chain from doing any harm by pressure. The origin and in- 
sertion of the artificial muscle are to be applied respectively over 
the origin and insertion of the tibialis-anticus muscle, and one or 
more muscles may be attached as the case may require. You 
should always cut a hole in the stocking for the chain to pass 
through, so that the artificial muscle can act freely upon the out- 
side. If low shoes are worn they will cause no obstruction to a 
free action of the muscle, but if a high shoe is worn it will be ne- 
cessary to cut a hole in the upper leather through which the chain 
is to pass, as through the stocking. When arranged in this way 
the artificial muscle can act without restraint. (See Fig. 59.) 

In moderate cases, all that may be necessary is a broad strip 
of adhesive plaster applied in such a manner as to give support to 
the weakened tibialis-anticus muscle, and firmly secured in posi- 
tion by means of a roller-bandage. (See Fig. 43, D.) 



72 TALIPES. 

LECTUKE IX. 

TALIPES. 

Talipes Plantaris. — Causes of Talipes. — Treatment.— Indications for. — When to begin. 
— How to effect a Cure without Tenotomy. 

Gentlemen : There is still another variety of the deformity 
which we have been studying, which must be briefly referred to 
before passing to the study of the causes and treatment of talipes. 
It is the form which has been called talipes cavus, but I prefer to 
speak of it as talipes plantaris. I believe that this variety of 
club-foot is, as a rule, acquired ; and that it sometimes results 
from some other variety already existing, while, at other times, it 
is the result of direct injury to the sole of the foot. 

It is a very frequent complication of other forms of talipes, 
and consists in a shortening of the plantar fascia, by which the 
heel and ball of the foot are approximated and the arch exag- 
gerated. 

This variety is often mistaken for talipes equinus, and section 
of the tendo-Achillis accordingly performed. The result is by no 
means beneficial ; the heel is simply dropped to correspond with 
the anterior part of the foot, and the arch becomes like an in- 
verted U. 

Causes of Talipes. — -I do not desire to discuss at length the 
numerous remote causes which have been assigned for the exist- 
ence of club-foot, and shall only refer to the immediate patho- 
logical condition that produces the deformity. 

The congenital forms are all due to some interference, general 
or local, with the normal innervation of the part. So much has 
been generally accepted, but the real nature of this nervous dis- 
turbance has been for the most part misunderstood. The prevail- 
ing treatment of talipes is based upon the theory that the patho- 
logical condition is a spastic muscular contraction. The muscles 
at fault in any given case have been considered to be those that by 
contraction would draw the foot into the position which it occu- 
pies. Talipes equinus is attributed to a spastic contraction of the 
gastrocnemius and soleus muscles ; talipes calcaneus to the same 
condition of the anterior muscles of the leg. So in varus, the 



CAUSES OF TALIPES. 73 

tibial muscles, and, in valgus, the peroneals and the extensor 
longus digitorum, have been considered to be the seat of dis- 
ease. 

The natural therapeutical inference from such a pathological 
theory was tenotomy, and it accordingly has become a sine qua 
non of treatment. 

Now, experiment and observation have fully demonstrated 
that in the immense majority of cases the pathological change 
is precisely contrary to that which has been believed to exist. 
Spastic contraction is the exception, paralysis the rule. The 
muscles supposed to be in a state of spasm are really contracting 
with only their normal degree of force, which produces an exces- 
sive effect, simply because paralysis of the opposing muscles has 
destroyed the natural harmony of action which exists between 
the tractile forces which govern the motions of the foot. I have 
said paralysis is the lesion, as a rule ; I believe, rather, that nearly 
all cases of congenital talipes, if examined immediately after 
birth, would be found to be paralytic in their nature, and that 
the spasm, or contracture, found to exist in some cases after a time, 
is really acquired, and due to irritation or inflammation of the 
muscles and fasciae involved, which inflammation is the result of 
their abnormal position, and consequently secondary to then- 
paralytic cause. Not that I would deny the possibility of such a 
spinal disease as should cause a tonic spasm of the muscles exist- 
ing in utero / but, if such cases do exist, they must be very rare, 
and, for myself, I have never seen them. 

If any one doubts the paralytic nature of these congenital de- 
formities, let him examine the first case he may meet within a 
few days after the birth of the child, and he cannot fail to mark 
the great ease with which the deformity can be reduced and the 
foot restored nearly or quite to its normal position, if he does not 
excite reflex contraction by too rapid and violent attempts at re- 
duction. 

"What has been said above, of the lesion in congenital talipes, 
is to a great extent true of the acquired form. Acquired talipes 
very generally is due to the various kinds of " infantile paralysis," 
which are the frequent sequelae of scarlatina, diphtheria, denti- 
tion, and many other diseases in which a blood-poisoning exists, 
or which are attended with great exhaustion. Yery many of 
the cases of this sort give a history of paralysis that originally 



74 TALIPES. 

involved the whole of the lower extremities, and frequently the 
upper. 

Some cases of acquired talipes, however, are not paralytic in 
their character: these are occasional cases dependent upon dis- 
eases of the spinal cord, in which treatment can be of little use 
while the originating disease is uncured ; cases following direct 
injury, which has caused inflammation and subsequent shorten- 
ing and rigidity of muscles and fascise ; and certain cases in 
which acquired spastic deformities are added to the paralytic 
ones previously existing. This last is a very common condition 
of things, and doubtless has been the chief cause in prolonging 
the belief in the spastic origin of most of these deformities. 

To apply these principles to special varieties of talipes, we 
must look for the seat of the disease, not in the muscles on that 
side of the leg toward which, but on that from which, the foot 
is distorted. In equinus, instead of the gastrocnemius and soleus 
being spastically contracted, the anterior muscles of the leg are 
paralyzed. The paralysis is often so extensive, that the only 
muscle retaining contractility is the extensor proprius pollicis, 
which, acting alone, at length produces a subluxation of the great- 
toe. {See Fig. 18.) In calcaneus, the gastrocnemius and soleus 
are paralyzed ; in varus, the peroneals chiefly ; in valgus, the 
tibials, and perhaps the long flexor. 

The seat of talipes has always till recently been supposed to 
be at the ankle-joint. If the ideas expressed in our former lect- 
ure, when describing the anatomy of the ankle-joint, concerning 
the motiou possible at the astragalo-tibial articulation, are cor- 
rect, then the only forms of talipes that could concern the ankle- 
joint are those where the heel is raised or dropped, equinus and 
calcaneus. Examination of cases of so-called equinus will satisfy 
any one that in them (with the exception of the few acquired 
cases having their origin in a traumatic contraction of the soleus 
and gastrocnemius) the heel is little if at all removed from, and 
can easily be restored to, its normal relation to the axis of the 
limb, there being really a dropping of the anterior portion of 
the foot ; and that, as in varus and valgus, the deformity takes 
place at the medio-tarsal junction. The deformity of calcaneus, 
which is dependent upon paralysis of the above-named muscles, 
does occur at the ankle-joint, and this I believe is the only vari- 
ety of which this is true. 



SEAT OF TALIPES. 75 

A further anatomical reason for the truth of this statement 
regarding the seat of deformity is this : Of the twelve muscles 
of the leg which move the foot, nine, namely, the tibialis anticus, 
extensor proprius pollicis, extensor longus digitorum, peroneus 
tertius, flexor longus pollicis, flexor longus digitorum, tibialis pos- 
ticus, peroneus longus, and peroneus brevis, have their insertion 
anterior to the medio-tarsal junction, and but three — the gastro- 
cnemius, soleus, and plantaris — posterior to this articulation, these 
three muscles having a common insertion, by means of the tendo- 
Achillis, into the os calcis. It follows, as a matter of course, 
that any deformity dependent upon an abnormal condition of 
these three muscles, must have its seat at the articulation moved 
by them, namely, the ankle and the calcaneo-astragaloid articula- 
tion ; and that, if any of the other nine muscles be affected, the 
resulting distortion will be anterior to the medio-tarsal junc- 
tion. 

This inference, drawn from the anatomy of the foot, will be 
practically confirmed by the observation of the cases which I 
shall have frequent opportunity to present to you. It is a matter 
worthy of remark how flat a denial is given to the statements of 
many standard works upon orthopedic surgery by the cuts with 
which these very works are illustrated — the description being 
made to accord with a false theory, and the illustrations being 
copied from the really-existing deformity. 

The vertical displacement taking place at the medio-tarsal 
junction is shown in Fig. 54, which is a reduction from a tracing 
made by laying the foot upon a piece of paper and carefully car- 
rying a lead-pencil around its contour. 

The lateral divergence is readily shown by tracing upon a 
piece of paper the outline of the sole of the first case of varus 
that presents itself, and comparing the tracing with that of the 
opposite foot, if it be sound, or with that of any normal foot of 
similar size. You will find that the deformity does not consist 
in a twist at the ankle-joint, by which the toes are thrown inward 
and the heel outward, but that the flexion occurs at the arch of 
the foot. The heel and posterior part, about one-third of the de- 
formed foot, will coincide with that of the normal one, while the 
anterior part turns suddenly inward at the middle of the tarsus. 
{See Tig. 30.). 

The resultant complications of talipes are : the effects of in- 



76 TALIPES. 

flammation or irritation ; defective nutrition of the foot and leg ; 
and the effects of pressure in changing the bony structure. 




Fig. 30. 

Inflammatory action is sometimes set up in the muscles as the 
result of direct injury ; this is very frequently the case with the 
fascise and integuments in the sole of the foot. The result in 
either case is a permanent shortening of these tissues, which be- 
come then one of the first obstacles to be overcome in the treat- 
ment. But contracture is produced in another way. The mus- 
cles that have remained sound, if unirritated, contract only with 
a normal degree of force ; but a constant source of irritation is 
found in the malposition of the foot. Pressure being made in 
abnormal directions, and upon surfaces not prepared for its re- 
ception, especially if inflammation has heightened the sensibility, 
causes frequent reflex contractions of the muscles. Contracture 
is the physiological result of this prolonged contraction. 

The effect of talipes, in preventing proper nutrition, is seen 
in the atrophy of the leg, or entire limb, the smaller size of the 
foot as compared with its fellow, as well as its lowered tempera- 
ture and livid color. The atrophy of the leg is due to the pa- 
ralysis of one set of muscles, and the gradual wasting of the sound 
ones, from want of the exercise necessary to keep them in proper 
condition. The same want of exercise will partly account for 
the arrest of growth in the foot, but mainly it depends upon the 
diminution of the supply of arterial blood sent to the part, and 



TREATMENT. 77 

the obstruction of the return of the venous blood, caused by the 
malposition of the vessels of the foot. A hose will carry water 
a given distance with a certain force applied, when the tube is 
straight and unobstructed; but the same hose, with the same 
amount of force, will carry the water a much shorter distance if 
the tube be bent at an acute angle, and particularly if these an- 
gles be increased in number. So an artery, supplying any part, 
will do it better when in its natural position than it can do when 
bent around a bone, or bent upon itself, which partially closes its 
calibre, and by abnormal pressure diminishes the amount of blood 
flowing through it, within a given space of time. The veins also, 
by this distorted position, are prevented from returning the blood 
as freely as natural, thus causing all deformed feet to present the 
blue and cold appearance spoken of above as so characteristic of 
them, which is the result of venous congestion. 

Moreover, when the disease is allowed to continue till adult 
life, an actual deformity of the bones of the tarsus occurs. Not 
only is the normal relative position of the bones changed, but the 
long-continued pressure in the new position brings about event- 
ually a change in their articular facets. The weight of the body 
upon these deformed feet aggravates the deformity, till the foot 
becomes a misshapen mass, covered with callosities, and is some- 
times quite inadequate to sustain the body without artificial as- 
sistance. Locomotion becomes laborious, painful, or even impos- 
sible. We sometimes meet adults with deformity of so grave a 
character as to make amputation and the use of artificial feet a 
beneficial change. 

Whenever the deformity has proceeded to the degree of alter- 
ing the shape of the bones, we can hardly hope for a perfect 
cure; for, however carefully and frequently the deformity be 
corrected, the bones cannot fail to return to the new articulations 
which have taken the place of the normal ones, if the artificial 
means of retention be removed. 

Treatment. — We are now ready, gentlemen, to study the 
treatment of talipes. 

From the characteristics of talipes above given, namely, the 
malposition and defective nutrition of the foot, it follows that the 
prime indications for treatment will be — 

1. To restore the foot to its normal position. 

2. To assist the nutrition by all the means within our reach, 



78 TALIPES. 

such as heat, friction, motion, galvanism, injection of strych- 
nine, etc. 

Proper treatment should fulfill both these indications ; many 
plans have been proposed that met only the former, and conse- 
quently the success attending them has been incomplete. The 
second can hardly be accomplished at all if the first be neglected. 

First, then, of the means to be employed for restoring the foot 
to its normal position. "Whatever method of treatment you decide 
to adopt, there is an important principle which should govern its 
application, and this must be taken into consideration at the very 
outset. The principle is, treatment of congenital club-foot should 
begin at hirth. This principle has already been laid down in my 
book upon club-foot ; but, as proof that it has not been an- 
nounced with force sufficient to attract the attention it justly 
deserves, I may mention that I have this day received a letter from 
a very distinguished physician of this city, containing an inquiry 
with regard to the proper time to commence treatment in this 
class of cases. Treatment of these cases should he commenced the 
instant the child is horn. The busy practitioner may, perhaps, be 
excused if he shall first see that the third stage of labor is com- 
pleted, and the necessary duties of the lying-in chamber dis- 
charged, but, as soon as these duties are discharged, the feet of 
the child should receive attention, and the proper treatment be in- 
stituted before the medical attendant leaves the house. In cases 
of acquired talipes, the rule is equally important, and treatment 
should be commenced immediately upon the receipt of the injury. 
Every day, week, or month, that treatment is neglected, dimin- 
ishes the chances of its success when finally resorted to. 

In congenital talipes, if treatment is begun at birth, we may 
reasonably expect that, by the time the child is old enough to 
stand, the feet will be so nearly in the normal position that the 
attempt at walking will complete the cure, rather than aggravate 
the case, as it will do when treatment has been neglected. In a 
large majority of cases, if proper attention is paid to the correc- 
tion of the deformity, from the birth of the child onward, the 
foot can be made to maintain the normal position without the aid 
of tenotomy. The importance of this rule and its observance 
can be seen at once, if for a moment we refer to the most serious 
obstacles which stand in the way of successful treatment of 
talipes. The most serious difficulties are those which arise from 



TREATMENT WITHOUT TENOTOMY. 79 

the following conditions : 1 . Advanced stage of fatty degenera- 
tion in paralyzed muscles, due to prolonged neglect of the per- 
formance of their normal function ; and, 2. Effects of inflammation 
produced in the muscles and fascise by the irritation from walk- 
ing with the feet in an abnormal position. 

Both of these difficulties could be avoided, or greatly dimin- 
ished, by early attention to the case. This principle of early 
treatment appears to have been recognized by Hippocrates, who 
applied proper bandages immediately after birth, in cases of con- 
genital talipes. Why this sound practice should ever have fallen 
into disuse, it is impossible to say ; but certain it is that it was 
neglected to such an extent that, in the surgical text-books of fifty 
years ago, the subject is hardly referred to (a slight mention in 
Bell's " Surgery " is the only reference that I can find in any of the 
books of that date at my command) ; and, in practice, so little 
was done for the cure of club-foot, that within a quarter of a cen- 
tury it was extremely common to meet persons who had all their 
lives endured this deformity, without ever having undergone any 
treatment for its relief. 

How can the deformity be cured without the aid of tenotomy ? 

The best means of cure would be constant manipulation, and 
the retention of the foot in a proper position by the hand of an 
attendant. This, however, is unfortunately an impossible plan of 
treatment, although I have known cases in which a faithful nurse 
has very considerably diminished the deformity by constant han- 
dling. ]STo instrument can ever have the delicate adjustment, the 
nice application of power, without doing injury, which the human 
hand possesses ; and the degree to which any apparatus approxi- 
mates the hand in these respects is the measure of its excellence. 

Still, much can be done by the hand before the dressing, or 
instrument which may be selected, is applied, or during the inter- 
vals when it is removed for readjustment. The manipulation 
should be made in the following manner : 

Take the foot in the hands and rub it gently with a shampoo- 
ing motion. Hold it firmly in the hands, and gradually press it 
as nearly as possible into its normal position. While this is being 
done, the foot becomes quite white. When the limit of the pa- 
tient's endurance is reached, the foot should be allowed to fall 
back as it was before, and to rest for a few minutes. The opera- 
tion should then be repeated, and after several repetitions it will 



80 TALIPES. 

be found that, with very little discomfort to the patient, the foot 
can be brought nearly, or quite, to its normal position. The 
manipulations should not be continued so long, or used with so 
much force, as to excite inflammation or reflex contraction. 

Again, the foot should never be retained, by any dressing, any 
nearer to a normal position than can be done without endangering 
free circulation. When, therefore, you apply the first dressing, 
you may not be able to restore the foot to its normal position, but 
must be content with a partial restoration, one which will permit 
a free and unobstructed circulation in the parts. 

At the second dressing, the foot can be restored still nearer to 
its normal position, and yet permit free circulation ; and thus you 
will go on, step by step, until complete restoration has been ob- 
tained. 

If the foot is restored at once to its normal position and held 
there by some apparatus, regardless of a free circulation (indicated 
by the color of the toes), sloughing will probably supervene, and 
your treatment will be delayed for a considerable time. The 
shampooing friction of the muscles should be very thoroughly 
applied, and, in addition, they should be lightly whipped with the 
fingers transversely to their fibres. If a muscle be struck so that 
the blow falls in the direction of the fibres, the contraction pro- 
duced is far less than if the blow be received transversely ; the 
object being to awaken the paralyzed muscles to action, the latter 
method is far preferable. These manipulations, by drawing a 
large supply of blood to the part, very much increase its nutrition. 
They should be repeated daily if possible, and I consider them 
of so much importance that I greatly prefer those forms of dress- 
ing which do not interfere with these and other kinds of accessory 
treatment. 



METHODS OF DRESSING. SI 

LECTURE X. 

TALIPES. 

Treatment (continued). — Methods of Dressing. — Splints.— Adhesive Plaster. — Barwell's 
Apparatus. — The Author's Club-Foot Shoe. — Crosby's Substitute for the Shoe. — 
Neil's Apparatus. — Case. — Talipes Varo-Equinus. 

Gentlemen : To-day we will continue our study of the treat- 
ment of talipes by describing some of the methods of dressing 
that may be employed for correcting the deformity without hav- 
ing recourse to tenotomy. 

To describe in detail the various plans which have been sug- 
gested would occupy too much time. I shall mention only the 
principal ones, which are really valuable, and, as briefly and 
clearly as possible, point out the indications for, and objections to, 
each plan. 

The simplest of all is the ordinary roller-bandage. If the 
patient be taken while the case is yet recent, by bringing the foot 
as near its proper position as possible, and carefully bandaging it 
to retain it there, and by constant observation and readjustment of 
the dressing, a cure may sometimes be effected. There are very 
considerable objections to this plan of treatment, viz. : it is appli- 
cable to. a very limited number of cases ; it is very liable to get 
out of order, and therefore demands constant care; it has, more- 
over, an objection, in common with all which permanently cover 
the limbs by bandages, or splints, that it interferes with the nec- 
essary application of frictions and galvanism. 

The gypsum bandage possesses the advantage over the last 
plan that it does not change its form ; the limb is as securely 
locked as in a vice. In the details of its application, quite a con- 
siderable variety exists — some preferring to first bandage the 
limb, and then to cover the bandage with the gypsum mixed with 
water ; others, to fill the meshes of a loosely-woven cotton roller- 
bandage with the dry powder, and to moisten it after it has been 
applied ; and others, again, to make from woolen or cotton cloth 
a covering to fit the leg, and to apply to this the plaster. These 
varieties are, however, immaterial; the property which gypsum 
possesses, of " setting " when wetted, is the essential one to bring 
into operation. The objections to this plan are, the weight of 
6 



82 TALIPES. 

the dressing, the impossibility of inspecting the limb, and of 
applying to it' friction, electricity, etc., as before mentioned. 

Again, splints of sole-leather and gutta-percha have been rec- 
ommended as a plan of treatment. A pattern is fitted to the 
limb held in the position desired. The leather or gntta-percha is 
softened by immersion in water (if the former is nsed, cold water 
is necessary, as hot water shrivels it ; if the latter, boiling water 
is necessary to warm the material) ; it is then moulded first to 
the foot, after which the foot is gradually and slowly forced 
around into its natural position, and firmly held there while the 
leg-part of the splint is moulded to the limb above and secured 
by the continuation of the roller, and carefully held in the re- 
quired position until the splint is hardened. Leather is to be 
preferred to gutta-percha, owing to its greater cleanliness and 
accessibility. Both leather and gutta-percha are superior to 
gypsum, in that they can be daily removed for personal inspection, 
manipulation, friction, shampooing, and electricity. 

Another article which I have employed of late with great 
satisfaction is, Ahl's felt-splint. This material is light, has no 
offensive odor, can be easily moulded to fit any irregularities of 
surface when softened by being dipped in boiling water, and 
hardens quickly by being dipped in cold water, and is com- 
paratively inexpensive. For the sake of convenience in its 
application, I have had made for my own use a wooden model 
of the foot and leg of a child of medium size. Over this model 
the felt can be moulded with the greatest ease, and it is suffi- 
ciently accurate for any foot within its limits ; for these feet are 
always smaller than normal, and can be easily padded to fit the 
model. 

Before applying any of the bandages or dressings above de- 
scribed, the limb should be enveloped in cotton, or, what is bet- 
ter, wool (the advantage of the wool is its elasticity, which pre- 
vents its becoming compressed or irritating to the skin, while it 
seems to be rendered foul by the perspiration no more quickly 
than the cotton) ; this prevents the permanent dressing from ex- 
coriating or unduly constricting the limb at any point. Great 
care should be taken that no foreign matter be entangled in the 
fibres of the cotton or bandages, as very severe excoriations and 
ulcerations may be produced by them. I have been obliged to sus- 
pend treatment owing to a grain of sand in the cotton. The small 



ADHESIVE PLASTER. 83 

shells found in compressed sponge sometimes cause the same 
trouble. 

A large majority of congenital deformities, if taken immedi- 
ately after birth, can be easily restored to, and retained in, their 
normal position by adhesive plaster. This can be applied in the 
following manner : 

Cut a piece of strong adhesive plaster, (flaw's moleskin is the 
best) from two to four inches in width, and of sufficient length 
to go nearly around the foot and to extend some inches upon the 
thigh. Commence on the dorsum of the foot with one extremity 
of the plaster at a slightly oblique angle, and wind it around the 
sole smoothly in the direction in which the foot is to be drawn ; 
then with the hand draw the foot as nearly as possible into the 
natural position, and carry the plaster up the leg and secure it by 
a well-adjusted roller as far as the head of the fibula ; as the plas- 
ter was cut longer than the leg, the end can* then be reversed 
with the plaster outside, over which the roller is again carried 
down the limb, and the plaster will thus prevent it from slipping. 
Care must be taken not to have the plaster completely encircle 
the foot, and a few nicks cut in the edge nearest the ankle may 
be necessary to prevent strangulation of the circulation, when 
the foot becomes flexed. A second strip of adhesive plaster may 
be applied in the same manner over the first bandage if the foot 
requires still greater traction than that afforded by the one 
applied first. The same care, however, must be exercised with 
respect to completely encircling the foot when applying the 
plaster over the bandage as when applying it to the naked skin. 

Such small points, gentlemen, may appear to you as unworthy 
of mention, but it is the neglect of these little things which has 
been the cause of many failures in the treatment of deformities ; 
and I think, therefore, that nothing can be so insignificant as 
to be unworthy of your attention which has proved in practice to 
be of real value to me. 

Although this plan is frequently successful, cases do occur in 
which the muscular rigidity is too great to yield to manipulation, 
unless continued for a longer time than can be generally given. 
A constant tractile force then becomes necessary, and the plan 
suggested by Mr. Kichard Barwell, of London, is by far the best. 
This consists in cutting from stout adhesive plaster spread on 
Canton flannel, or the " moleskin plaster," a fan-shaped piece. In 



84 



TALIPES. 



this are cut several slips, converging toward the apex of the piece, 
for its better adaptation to the part. {See Fig. 32.) The apex 
of the triangle is passed through a wire loop with a ring in the 
top {see Figs. 31 and 32), brought back upon itself, and secured 



Figs. 31. 32 




by sewing. The plaster is firmly secured to the foot in such a 
manner that the wire eye shall be at a point where we wish to 
imitate the insertion of the muscle, and that it shall draw evenly 
on all parts of the foot when the traction is applied. Secure this 
by other adhesive straps and a smoothly-adjusted roller. 

The artificial origin of the muscle is made as follows : Cut a 
strip of tin or zinc plate, in length about two-thirds that of the 
tibia, and in width one-quarter the circumference of the limb. 
{See Fig. 35.) This is shaped to fit the limb as well as can be 
done conveniently. About an inch from the upper end fasten an 
eye of wire. Care should be taken not to have this too large, as 
it would not confine the rubber to a fixed point. The tin is se- 
cured upon the limb in the following manner : From the stout 
plaster above mentioned cut two strips long enough to encircle 
the limb, and in the middle of each make two slits just large 
enough to admit the tin, which will prevent any lateral motion ; 
then cut a strip of plaster, rather more than twice as long as the 
tin, and a little wider ; apply this smoothly to the side of the leg 
on which the traction is to be made, beginning as high up as the 
tuberosity of the tibia, Lay upon it the tin, placing the upper 
end level w T ith that of the plaster. {See Fig. 36.) Secure this by 



BARWELL'S DRESSING. 



85 



passing the two strips above mentioned around the limb (see Fig. 
37), then turn the vertical strip of plaster upward upon the tin. 
A slit should be made in the plaster where it passes over the 
eye, in order that the latter may protrude. The roller should 
then be continued smoothly up the limb to the top of the tin. 
The plaster is again reversed, and brought down over the bandage, 
another slit being made for the eye, and the whole secured by a 
few turns of the roller. A small chain, a few inches in length, 
containing a dozen or twenty links for graduating the adjust- 
ment, is then secured to the eye in the tin. 

Into either end of a piece of ordinary India-rubber tubing, 
about one-quarter of an inch in diameter and two to six inches 
in length, hooks of the pattern here exhibited (see Fig. 33) are 
fastened by a wire or other strong ligature. One hook (see Fig. 
34) is fastened to the wire loop on the plaster on the foot, and 
the other to the chain above mentioned, the various links making 
the necessary changes in the adjustment. 

The dressing, when complete, is shown in Fig. 37. 





From Barwell. 



Fig. 37.— From Barwell. 



The constant traction of this rubber tubing is sufficient to 
overcome the strongest muscles, if they have not already under- 



86 TALIPES. 

gone structural changes, 1 i. e., if they have not become contrac- 
tured (permanently shortened), or if fasciae have not become 
contracted as the result of inflammation. 

The advantage of this plan of treatment over any of the 
others proposed, where the limb is forced into its position, and 
there securely fixed by the retaining apparatus (whether it be 
plaster of Paris, or complicated machinery with screws and cogs, 
and which can only be altered by the key of the attendant), is, 
that it causes movements in imitation of the natural movements 
of the parts ; permitting and promoting the constant movement 
of the muscles and joints, thereby increasing the circulation in 
the same, and necessarily improving their development and 
power. i 

The joints and muscles of the human body were designed for 
active motion, and so far as is possible these natural movements 
should be retained, stimulated, and strengthened. It is for this 
reason that I always condemn any apparatus, devised for the cure 
of this class of deformities, that places the foot in a rigidly-fixed 
position. The deformity is essentially paralytic in its nature, 
and treatment of paralytic deformities by retention in a fixed ap- 
paratus, is all wrong. Such apparatus, therefore, as plaster of 
Paris, gutta-percha, or shoes made with a certain set of iron fast- 
enings and screws, by means of which the foot is held in a certain 
fixed position, are erroneous in principle. 

The permanent fixing of any limb or joint in a stationary ap- 
paratus, thus preventing even the healthy muscles from contrac- 
tion and relaxation, will sooner or later cause even these muscles 
to become atrophied, and undergo fatty degeneration ; and cer- 
tainly this plan of treatment could never have a tendency to 
develop the latent power of a partially-paralyzed muscle ; but, on 
the contrary, would have a tendency to place it in a condition be- 
yond all hope of ever again being able to perform its normal func- 
tions. 

I cannot, therefore, too frequently urge the necessity of mo- 
tion as a means of permanent cure, or too strongly deprecate the 
use, for any length of time, of any form of appliance which shall 
prevent or materially limit the proper movements of the foot. 
"Without motion, the muscles cannot be restored to their normal 

1 If the rubber tubing is not stretched beyond six times its length, it will continue 
to contract to its original length for an indefinite period of time. 



IMPROVED SHOE. 87 

degree of development, and consequently the talipes will be 
cured only in form, and not in reality, and relapse will be the 
natural sequence of such incomplete treatment. Motion is the 
essential element of cure ; and I think the chief value of gal- 
vanism and f aradism, as promoters of muscular growth, lies in the 
muscular contractions which they produce. The growth is the 
result of action. By the application of the elastic rubber, or con- 
tracting force, in just such a degree of strength as shall overcome 
the distorting muscles only, after a tension on them for a short 
time, in order to produce fatigue, and as shall not prevent them 
from contracting by an effort of the will, and thus redistorting the 
part, a constant motion is produced in the deformed and partially 
paralyzed limb, similar to that which occurs in the act of walking, 
which will materially assist the circulation, raise the temperature 
of the part, and manifestly has a tendency to improve its nutri- 
tion and increase its power. The exact amount of force applied 
can be regulated at will by means of the chain attached to the 
tubing. The change of the hook from one link to another in- 
creases or decreases the power according as the length of the chain 
and tubing is diminished or increased. A very little practical ex- 
perience will soon indicate the amount of force required in each 
case. The only objection that can be urged against this plan of 
treatment is, that the adhesive plaster will sometimes slide and 
change its position ; will soon become worn out, and require fre- 
quent readjustments ; and, what is the most annoying, will often, 
particularly in very young children, and in hot weather, so irritate 
and excoriate the skin as to compel, for a while, the abandonment 
of its application. 

This can be remedied to considerable extent by first carrying 
a flannel roller over the foot and leg before applying the plaster. 
Of course, this will require a more frequent application of the 
dressing, inasmuch as the roller will get loose and slip down the 
leg. 

To permanently overcome or remedy this defect, I constructed 
a club-foot shoe, on the general plan of the " Scarpa's shoe," with 
a lateral hinge in the sole, for cases of valgus and varus ; the only 
difference being that the motive power was the rubber tubing in 
place of the ordinary different kinds of springs which had former- 
ly been used for this purpose. 

Just here it may be remarked that the shoe should not be 



88 TALIPES. 

resorted to until the child is old enough to walk. It is exceed- 
ingly difficult to properly adjust a shoe to the foot of a little 
child, and much more so in a case of club-foot. . It is far better 
to use Barwell's apparatus or the simple strip' of adhesive plas- 
ter, or alternate them, until the time arrives when the child can 
walk. 

As all distortions of the valgus and varus varieties in- 
volve the medio-tarsal articulation, no shoe is applicable for 
their treatment that has not a joint in the sole opposite this 
articulation, and any shoe for the treatment of these varieties 
of club-foot that has a solid or immovable sole is not con- 
structed upon physiological principles, and is, therefore, worse 
than useless. 

This shoe which you see here was constructed in December, 
1867, for a little child four years of age, that had been subjected 
to tenotomy several times, and had worn, almost since birth, 
heavy instruments of various kinds, only omitting them when the 
ulcers and excoriations were so great that danger was appre- 
hended from continued pressure. None of the shoes that she 
had worn had been constructed upon correct principles, viz., that 
of imitating natural movements / and the pair that she had on at 
the time I first saw her had neither motion in the soles nor at the 
ankles — in fact, were simple straight bars of steel, bolted at right 
angles to steel soles ; and into these prisons the doctor had en- 
deavored to force and secure the feet by straps and bandages in 
different directions, but the pain was so great as to require 
changes every few hours, and frequently he had been compelled 
to omit the treatment for several days together, in order that the 
skin might heal. And yet these shoes had been contrived and 
applied by a gentleman of very great reputation in orthopedic 
surgery. Even when the bandages were adjusted most carefully, 
the child could only walk in an awkward manner, on the outer 
edge of the soles, being unable to balance herself unless held by 
an assistant, no motion whatever taking place at the ankles or any 
of the joints of the feet. The father of the child, a very intelli- 
gent physician, kindly permitted me to exhibit the case to my 
class in this room, as I was lecturing on that subject at the 
time. 

The practical working of the shoe is so well described by the 
editor of the Medical Gazette, in the number of December 28, 



IMPROVED SHOE. 



89 



1867, that I will take the liberty of ' transcribing his report in 
that journal : 

" An Impeoved Club-Foot Shoe. — Dr. Sayre exhibited and applied at his 

last lecture a pair .of club-foot shoes to the little child of Dr. , of New 

Jersey, which, in then* mechanical construction, ease of application, and 
efficiency of action, surpassed anything of the kind we have ever seen, and 
which will doubtless soon replace all the cumbersome machinery hitherto in 
use in this unfortunate class of deformities. 

"Dr. Sayre regards almost all the cases of club-foot as being of & paralytic 
origin, and therefore the necessity arises of supplying some artificial, con- 
stantly contracting force, to take the place of the paralyzed muscles, as the. 
only means, in addition to galvanism and friction, that is necessary to restore 
them to their normal position ; and by the proper adjustment of this force 
almost all of these deformities can be rectified, without resorting to tenotomy. 
This is certainly a very great improvement in their treatment. The simple 
yet efficient plan suggested by Mr. Barwell, of applying elastic tubing, 




Fig. 33. 



secured at the points desired by the means of adhesive plaster, has the very 
serious objection of irritating the skin, which, in young children, is very 
annoying, sometimes necessitating omission of its application for several days, 
and at the same time interfering with the manipulations and frictions which 
are so essential in their treatment. The simple but ingenious shoe contrived 
by Dr. Sayre is so constructed that it can be applied and secured accurately 
to the deformed foot before the elastic force is attached, instead of adjusting 



90 TALIPES. 

the foot to the shoe, while the power is acting, as is the case in all other in- 
struments, and this is the essential difference between it and the ordinary 
shoe with a jointed sole now in use, after which it is modeled. 

"The accompanying drawing (Fig. 38) gives a very correct idea of its 
construction and mode of action. 

"The shoes were applied in this instance with the most satisfactory 
results, the child in a short time after their adjustment running about the 
lecture-room with her feet on the floor in a natural position, which had 
never been accomplished by any of the numerous instruments she had 
formerly worn." 

In January of 1868 I improved this shoe by putting in the 
sole, opposite the medio-tarsal articulation, a ball-and-socket, or 
universal joint, instead of the hinge- joint, which permitted only 
lateral movements. This sole and part embracing the heel con- 
sists of strong sheet-steel, covered with leather on both sides. 
Two lateral upright bars, B, jointed at the ankle, are fastened 
near the heel and to the collar-band ; G, II, and 7, are points for 
the attachment of artificial muscles, made of rubber tubing, with 
hooks and chains at their ends. To the inside walls of the shoe 
near A, two flaps of chamois-leather are attached to lace together, 
which, passing over the front of the ankle-joint, keep the heel 
firmly in the back part of the shoe. The accompanying figure 
shows the result of the last effort to make this shoe resemble an 
ordinary one as much as possible. 

MEASUREMENTS REQUIRED. 

1. Trace the outlines of the affected foot on a piece of paper. 

2. Circumference at I y K, A, A E, z. 

3. Length of foot. 

4. Length from sole to below knee. 

5. Circumference of leg below knee. 

In addition, the shoe has been made more comfortable and 
convenient by a slight heel, and by making the anterior part of 
the sole like that of an ordinary shoe, and not so clumsy as that 
of most club-foot shoes. The upper leather laces neatly over 
the foot, adapting itself more perfectly than if arranged with 
straps and buckles. (See Fig. 39.) The shoe as applied is seen 
in Figs. 60 and 61. 

The shoe pictured above is arranged for valgus or varus. 
There is really no essential difference between the different forms 
of talipes, and the single principle is to apply the artificial 



CROSBY'S SHOE. 



91 



muscles in such position as shall best supply the place of those 
paralyzed. 

My friend and colleague Prof. A. B. Crosby informs me that 
he has made a very cheap and serviceable substitute for my shoe, 
in the following manner : Having procured a pair of stout shoes 
which fitted the patient well, he cut the sole of the one for the 




Fig. 39. 



deformed foot quite across, opposite the meclio-tarsal junction. 
The two parts he connected by two links of chain, and made the 
necessary eversion or inversion by elastics. If to this an upright 
of tin or sheet-iron were added, for the application of muscles 
for the elevating of the toe, I doubt not it would serve every 
purpose in most cases. 

Such a device will be of great service to gentlemen who prac- 
tise at a distance from cities, and who, therefore, find great diffi- 
culty in obtaining instruments. Many other succedanea will 
doubtless suggest themselves, for " necessity is the mother of in- 
vention." 

Certain things should be borne in mind (to which attention 
has already been called, but which will bear repetition) in mak- 
ing any dressing : the aim of the dressing or instrument is simply 
to imitate the action of the surgeon's hand ; and that is best 
which nearest accomplishes this, or which most readily permits 
the hand actually to be used ; accordingly, an apparatus combin- 
ing elastic force is far superior to any fixed appliance ; and, 



92 TALIPES. 

moreover, of the dressings constructed on this principle, that is 
to be preferred which is the most readily removable. Shoes, 
therefore, are better than bandages or splints. A proper shoe 
mnst have a joint opposite the main joints of the foot — the ankle 
and medio-tarsal junction ; it must be arranged for the ready 
application and adjustment of elastic power, and it must not 
girdle the limb at any point so as to interfere with the circula- 
tion. 

The plan of treatment devised and practised by Dr. Henry 
Neil, of Philadelphia, in 1825, and which was so well described 
by Dr. John L. Atlee, of Lancaster, Pennsylvania, when discuss- 
ing my report at the meeting of the American Medical Associa- 
tion in "Washington, May, 1 868, is so correct in theory — viz., 
compelling action in the partially-paralyzed muscles in order to 
remove the deformity — that I give the substance of Dr: Atlee's 
remarks, in order to claim for American surgery the credit of 
having first proposed the correct or physiological plan of treat- 
ment. Dr. Neil, although a gentleman of high professional 
standing and of great practical ingenuity, was not much of an 
author, and I can find no account of his treatment, although it 
may have been published in some of the medical journals of that 
date. None of the medical gentlemen present at the meeting 
had ever heard of the plan before ; and it is due to the memory 
of Dr. Neil that it should be permanently recorded to his credit. 
The plan of treatment is simply to fasten the child's feet to a 
board made to fit the soles of the feet, and joined together op- 
posite the ankle-joints. The restraint is, of course, irksome to 
the child, and, in his efforts to kick himself out of the bandages, 
he brings into action all the muscles of the legs — accomplishing 
the very object desired — and, in the graphic language of Dr. At- 
lee, " kicks himself straight." 

To make an apparatus of this kind to fit the child, you place 
his foot on a piece of folded paper, about one inch and a half or 
two inches from its folded edge ; mark with a pencil the size of 
the child's foot, commencing at his inner ankle, and going round 
the heel, the outside of the foot and toes, and back to within one- 
half inch of the starting-point. From these two points draw 
lines at right angles to the folded edge of the paper, and then 
with scissors cut the double paper, and when unfolded you have 
the pattern from which any carpenter can make, in a few min- 



NEIL'S PLAN. 93 

utes, the necessary board out of light but strong wood. {See 
Fig. 40.) 

A strip of leather is folded into a loop and nailed at either 
heel, through which a strip of adhesive plaster is passed, and car- 




Fig. 40. 



ried in a "figure of 8" over the instep and around the foot- 
board. Such other bandages as are needed to secure the foot in 
position are of course applied in the proper manner. 

I have tried this plan in several cases, and have been well 
pleased with the result, but do not find it as satisfactory as 
the adhesive plaster and India-rubber spring, as it gives the child 
considerable uneasiness, and few mothers will submit to the con- 
tinuance of a plan of treatment which causes such distress to " the 
baby." 

Case. Paralytic Talipes Yaro-Equinus. — The case now before 
you, gentlemen, is a very good illustration of the paralytic variety 
of talipes, and also shows you how easily it can be overcome by 
an elastic force to take the place of the paralyzed muscles. 

This boy, now eight years old, was paralyzed when twenty-one 
months of age. He recovered from his paralysis — with the ex- 
ception of the muscles of his right leg — more particularly the 
peroneals. 

He has worn stiff braces almost constantly since he was large 
enough to walk ; only laying them by when the pressure had 
become unbearable, to be resumed again as soon as the points of 
inflammation would permit the application of the torturing in- 
struments. 

He was sent to our clinic last week, you will remember, to 
have tenotomy performed. Of course, I did not do it, as the op- 
eration would only have increased his difficulty. 

Mr. Reynders has made for him one of my club-foot shoes, 
and Mr. Mason has this morning taken a photograph of his foot 



94 



TALIPES. 



— without the shoe — and another with it on. Both of these pict- 
ures were taken within a few minutes of each other, and beauti- 
fully illustrate the advantages of this plan of treatment ; as you 
now see, this boy walks perfectly well, with his foot in natural 




Fig. 41. 



Fig. 42. 



position when the rubber elastics are properly adjusted. {See 
Figs. 41 and 42.) 

So much, gentlemen, for the management of that class of cases 
of club-foot that can be rationally and successfully* treated with- 
out resorting to any operation. 



TENOTOMY. 95 

LECTUKE XL 



TALIPES. 



Treatment (continued). — Tenotomy. — Indications for same. — Dressing applied after 
the Operation. — After-Treatment. 

Gextlemeit : Thus far we have been studying the treatment 
of talipes in those cases which may be cured without resorting to 
the knife. Unfortunately, however, the great majority of cases 
that fall under our care require tenotomy ; and almost without 
exception require such operative interference, simply because 
a rational method of treatment has not been put in practice early 
in their history. This brings us to the study of tenotomy as con- 
nected with the treatment of club-foot. From the publication of 
Stromeyer's work, in 1831, dates a new era in orthopedic surgery. 
The operation of tenotomy, advocated by him, found many 
friends ; and, from the surprising nature of its results, became 
rapidly popular. It was brought into general use by Dr. William 
Detmold, of this city, who had himself been a pupil of Dieff en- 
bach and Stromeyer. The immense advantages which this plan 
of treatment possessed over the let-alone method for some time 
reudered the profession blind to the disadvantages attending it. 
After a time, however, surgeons noticed that all cases of club- 
foot were not cured by tenotomy, and many that had appeared 
to be cured afterward relapsed. 

This failure was due in some cases to the neglect of proper 
after-treatment, but generally to the fact that the operation of 
tenotomy was based in many cases upon a false pathological the- 
ory, namely, that the deformity was due to a spastic contraction 
or abnormal shortening of the muscle, the tendon of which was 
to be cut. 

If what I have told you regarding the paralytic origin of most 
cases of club-foot is true, then the severing of the tendons of mus- 
cles still remaining sound is entirely irrational. The very best 
result that could be expected from the operation would be, that 
the muscular support of the foot being removed on all sides, 
gravity would throw it into a normal position. The disease 
which underlies the distortion, namely, the paralysis, has been 
untouched. And, if the tendon becomes firmly reunited, there 



96 TALIPES. 

is likely to be a complete relapse of the deformity ; if the union 
is incomplete, the foot hangs as helpless at the end of the leg as 
the flail of the thresher. 

But, while I believe that in cases of congenital or acquired 
paralytic talipes, if taken in hand early, tenotomy is very rarely, 
if ever, needed, cases frequently present themselves where, from 
neglect, it is absolutely essential, as a preliminary measure to all 
other treatment. These cases are those in which the fasciae or 
muscles have become contractured. By confrractured, I mean a 
tissue that has undergone structural change, and cannot be 
stretched or lengthened without severing its fibres either by the 
knife or force. 

Now, how is this contracture to be diagnosticated ? By anaes- 
thetizing the patient, and then attempting to reduce the de- 
formity. If the contraction yields without the rupture of any of 
the tissues, the condition is one of simple contraction, and can 
be relieved without section. If, however, the deformity persists, 
contracture has taken place, and tenotomy or rupture of the 
shortened tissues is demanded. 

I have been obliged to cut the plantar fascia in a child of only 
fourteen months of age, that had walked less than two months, 
and whose history showed that the contracture had taken place 
during the last-named period. 

The law by which you are to be governed in determining 
whether a muscle, tendon, or fascia, must be cut, has already 
been fully laid down in a previous lecture, but its importance is 
such that I shall offer no apology for repeating it. It is this : 
Put the parts to be examined upon the stretch to their fullest 
extent, and, while thus stretched, press with the finger or thumb 
upon the tendon or fascia thus made tense ; and if this additional 
point-pressure produces reflex contractions, that muscle, fascia, or 
tendon, must be divided, and the point of pain is the point for 
the operation. If, on the contrary, the additional point-pressure 
thus applied does not produce reflex contractions, the contraction 
can be overcome without cutting, and by the application of con- 
stant elastic tractile force. 

A full description of the manner in which the operation 
should be performed, and the instruments to be used, has also 
been given ; hence it will not now be necessary to go over these 
subjects again. (See Figs. 10 and 11.) 



DRESSING AFTER TENOTOMY. 97 

We will therefore pass at once to the consideration of the 
dressings to be applied after the operation has been performed. 

After division of any of the tendons or fascia for the relief of 
the different distortions of the foot, and hermetically closing the 
wound in the manner already described, bring the foot immedi- 
ately into its natural position, or as nearly so as can be done, and 
retain it there by the following dressing : 

Cut a thin board (the top of a cigar-box answers very well) 
into the shape of the sole of the foot which is to be dressed, only 
a little longer, and square at the toe. 

Then take a piece of strong " moleskin " adhesive plaster, as 
wide as the board, and long enough to cover both sides of the 
same, and to reach some inches above the knee. 

Apply the adhesive side of the plaster to the board, com- 
mencing at the anterior extremity of the upper surface, passing 
backward over the posterior extremity of the board, and under 
the same to its anterior extremity ; the remainder of the strip is 
subsequently to be applied to the anterior surface of the leg. 

The foot is then placed on the board, A, and secured at the 
heel by a strip of the same adhesive plaster, B, passed over the 
ankle, and around the heel-part of the board, and additionally 
secured by a well-adjusted roller, which also extends above the 
ankle. The foot is now brought into its natural position, and 
the adhesive plaster, C } is firmly drawn up and secured to the leg 
by a continuation of the roller ; the superfluous extremity is to 
be reversed, bringing its adhesive surface outward, and the roller, 
carried back over it, will be more firmly retained in position. 

If the foot has a tendency to valgus, another strip of plaster, _Z>, 
is made to nearly encircle it, and is drawn upon the inner side of 
the leg to correct the deviation, and secured by a roller-bandage. 
(See Fig. 43.) If the deformity is a varus, of course this last 
strip of plaster is applied in the opposite direction, and secured in 
the same manner. I have found that this simple dressing answers 
much better than " Stromeyer's foot-board," or any other compli- 
cated form of apparatus that I formerly employed. It is simple, 
inexpensive, and effective. It is a plan of treatment that can be 
adopted in the country, without being obliged to send to the city 
for some kind of machinery, and is far better for the reason that, 
in a majority of cases, if you send to the instrument-makers, 
they will send you an apparatus that will require the services of 
7 



98 TALIPES. 

a special engineer to adapt it to the case, and then operate it. 
In a few instances where contraction of. the sole existed (see 
pages 00, 00), I have found that section of the plantar fascia was 
not sufficient to reduce the deformity. The integuments them- 
selves had become so shortened that they would not yield, and their 
section was indispensable, and followed by a ready cure. I have 




Fig. 43. 

seen the same condition exist in long-standing deformities of 
other parts of the body. 

Dr. Benjamin Lee, of Philadelphia, reported to the American 
Medical Association a case of severe talipes, of ten years' standing, 
in which he substituted hrisement force, or forcible rupture of the 
contractured tissues, for tenotomy, the child being under chloro- 
form. He says, in his report of the case : " These manipulations 
were made with all the force I was capable of exerting, and were 
occasionally accompanied by the audible rupture of ligamentous 
or fascial fibres. They were repeated every third day for three 
weeks." It remains for further experience to determine whether, 
in cases demanding operative interference, rupture or section is 
preferable. I am unable to offer any opinion, as hitherto I have 
used only the knife, or at least have never used rupture alone. 



AFTER-TEE ATMEXT. 90 

I have, however, several times been obliged to force into place 
tarsal bones, which have become dislocated, or rather subluxated, 
by the long continuance of the deformity. The complication oc- 
curs most frequently, I think, in varus, the projecting points being 
the head of the astragalus and anterior portion of the calcaneum, 
and sometimes the cuboid bone. This condition existed in cases re- 
corded on pages 115, 117, 136. The latter case, in particular, de- 
manded so great an amount of force to accomplish the reduction, 
that I anticipated sloughing of the integuments. Fortunately this 
did not occur, the indurations and callosities about the part being 
doubtless a source of protection in this instance. It is well, if much 
force has been used in the reduction of the luxation of the bones, 
to institute some after-treatment, with a view to diminishing the 
liability to inflammation ; elevation of the limb, cold applications, 
and slight compression of the arteries, will be found most service- 
able. 

^Vhen the tenotomv and bandaging have thus as nearly as 
possible restored the deformity to the condition which existed 
before inflammatory action had taken place, the treatment proper 
can be continued just as if the case were one of uncomplicated 
congenital talipes, and the patient be made to wear such dressings 
as BarwelFs apparatus or the shoes which have already been 
described. {See Figs. 36, 37, and 39.) There is one practical point, 
however, which may be mentioned relative to obtaining a shoe 
for a deformed foot, and that is, do not measure the foot until it 
has been unfolded and lengthened by the operation. If this 
precaution is neglected, it will almost invariably happen that the 
shoe will be made too small and too short, as seen in the last two 
cases brought before you. 

The next important part of the management of a case of club- 
foot is the treatment after the operation has been performed. 
"When you have done the cutting which may be necessary, you 
have simply put your patient in a favorable condition for the com- 
mencement of the treatment which is to cure the deformity. The 
operation may be necessary, but the case must receive a proper 
after-treatment, if you expect to have any benefit follow it. The 
simple application of an instrument also, however perfect it may 
be in its construction, is but a small part of the treatment of 
club-foot. As soon as the external wounds are healed, which is 
usually within a week or ten days, the foot is readv for the com- 



100 TALIPES. 

mencement of those passive movements, manipulations, etc., that 
contribute most to the cure of the deformity. Handling the 
foot, gentlemen, is the great secret of curing it. Friction, sham- 
pooing, whipping of the paralyzed muscles, and the manipula- 
tions so fully referred to in our second lecture, should be repeated 
daily. Cases are constantly coming to us in which tenotomy has 
been performed as many as five or six times, and yet the deform- 
ity remains as bad as when first operated upon, perhaps worse, 
and why ? Simply because the treatment adopted after the 
operation has been that by means of fixed apparatus, which was 
regarded as sufficient. What has occurred in such cases ? The 
parts being permitted to remain in a quiescent state, adhesions 
have taken place which render the case as bad as it was before 
the operation. 

The more frequently the foot of the patient is manipulated, 
the greater will be the benefit derived from the operation, pro- 
viding the manipulation is performed thoroughly, hut gently, and 
never carried to over-fatigue. Electricity is a very powerful ad- 
juvant for restoring lost .muscular power, and should be used in 
accordance with the rules already laid down, namely, always ap- 
proximate the origin and insertion of muscles to such an extent 
that they will not be compelled to carry any weight whatever, 
and maintain them in that position by some artificial support, 
while the battery is being used. Again, never continue the cur- 
rent sufficiently long to produce exhaustion. Strychnia is an- 
other valuable agent in many of these cases, and is to be admin- 
istered according to the directions already given under the head 
of general treatment of deformities. The nurse should be in- 
structed to watch for the occurrence of excoriations, as they, if 
allowed to take place, seriously retard the treatment. To prevent 
this, the application of astringents should be frequently repeated. 
If the treatment adopted is such as to require bandages, extreme 
care should be taken in applying and reapplying them. It may 
appear to you like an insignificant matter, but a single thread of 
ravelings from a bandage may upset the most seemingly com- 
plete surgical dressing ; and it may do this by girdling the limb. 
If at any time the dressing gives the patient very much discom- 
fort, remove it at once, and endeavor to find out why it does so ; 
for such timely precaution may save you weeks, perhaps months, 
of needless anxiety and care. You should always bear in mind 



AFTER-TREATMENT. 101 

the fact that these feet and limbs are much more sensitive to heat 
and cold, and all forms of irritation, than is natural, and at the 
same time, having much less vitality, will slough much more 
readily. A very common place for sloughing to occur is over 
the astragalus, where pressure often becomes necessary in order 
to restore the parts to their normal position. Care, therefore, 
should be exercised in applying such pressure. Pressure about 
the ball of the toe is frequently complained of, hence that part 
should be especially protected. 

The treatment should be persevered in for a long time. In 
the most favorable cases a few months may suffice for a cure, 
but, as a rule, the treatment should not be relaxed when the de- 
formity is apparently cured, but should be continued with the 
hope of developing the paralyzed muscles to the same or nearly 
the same degree as those of the sound limb. If this be accom- 
plished, relapse can hardly take place. 

It is true that in some cases the disease of the nervous system 
is so great that we may not restore the muscles to their normal 
contraction so soon as we would wish ; but even in these, the 
most unfavorable of cases, by the use of an instrument for retain- 
ing the foot in place, we shall at least have preserved the natural 
position of the feet, and thus have prevented the hideous deform- 
ity that would otherwise have resulted ; and, by the application 
of artificial muscles, to take the place of the paralyzed ones, have 
enabled the patients to walk without limping. The exercise they 
are thus enabled to take, while the blood-vessels are held in their 
natural relation to other parts, is the very best method of devel- 
oping the growth and nutrition of the limbs. Whereas, if they 
are permitted to walk without the feet being retained in their 
natural position, the weight of the body has a tendency to increase 
the deformity, and the abnormal position of the blood-vessels, 
both arteries and veins, interferes with the natural circulation of 
the parts, prevents development, and in fact tends to atrophy. 
The faradaic and galvanic currents will also have a much more 
beneficial effect upon the limb when retained in its natural posi- 
tion, than they have when applied with equal power while it is 
distorted. 

This, gentlemen, concludes what I have to say upon the sub- 
ject of club-foot in the theoretical course ; but in my clinical lect- 
ures I shall take occasion to reiterate the principles now laid 



102 



TALIPES. 



down, while I demonstrate them upon the cases brought before 
you. 

The following cases, most of which were treated before the 
class, will serve to illustrate the principles I have endeavored to 
inculcate. Some of them have been already published in my 
" Manual of Club-Foot." 

Case. Double Talipes Varus, congenital ; treated ~by Sole- 
Leather and Adhesive Plaster ; Recovery perfect. — On the 25th 
of March, 1863, I was requested by Dr. C, of ISTew Jersey, to 
see his little child, five days old, who had been born with talipes 
varus or varo-equinus of both feet. 

I saw the child on the same day, and found him very vigor- 
ous and robust and exceedingly well developed, with the excep- 
tion of his feet, which exhibited a very severe form of varus, with 
slight equinus, and which are well represented in Fig. 44. 

The feet were much colder than any other part of his body, 
and quite blue or purplish in color. 





Fig. 44. 



By grasping the foot in one hand, and the leg in the other, I 
could with some considerable effort, continued for a few minutes, 
evert the foot, and slightly flex it. The capillary circulation 
seemed to be arrested entirely when I did this, and the foot became 
as white as snow. After holding it in this position a few minutes, 
I would relax my hold, when the foot would immediately resume 
its abnormal position, and in a short time circulation would return 
to it as at first. 

I then performed the same operation on the other foot. After 
repeating these manoeuvres a number of times on each foot, allow- 
ing some minutes to elapse between each effort at straightening 
them, I found that I could bring them into almost a natural posi- 
tion, and retain them there by a very slight force. 



CASE. 103 

I then wrapped the feet and legs in cotton, and applied a piece 
of sole-leather previously softened in cold water, and cut into the 
shape of a half-boot. 

After the roller had been carefully adjusted, and the leather 
accurately modeled upon his foot, the foot was forcibly held as 
nearly as possible in its natural position, while the roller secured 
the rest of the leather to his leg. 

It was then held in this position with the two hands for a short 
time, until the leather had received its form, and, when perfectly 
dry, it held the limbs very securely in place. 

These bandages were removed on the third day, and the feet 
and legs well rubbed and moved in all directions. The leather 
was then again softened by soaking in cold water, and reapplied 
as at first, with the only difference that at this time the feet were 
forced completely around into a natural position, and held there, 
until the leather became dry and retained them there. The 
bandages and leather were removed every day, and the feet and 
legs freely rubbed and all the joints moved by the nurse, after 
which the bandages and leather were reapplied. 

This plan was pursued for five weeks, when it was found that 
the feet could be retained in their natural position by a very 
slight force. Strips of adhesive plaster were then applied, com- 
mencing on the dorsum of each foot, passing around the inner 
margin, and then, the foot being held well outward and flexed as 
much as possible, passing upon the outer side of the leg, where 
they were secured by a roller. 

This answered the purpose of holding the feet in a natural 
position, and at the same time admitted of slight motion at the 
ankle-joints. 

This plan was continued for some weeks, until the feet re- 
mained in their normal position without artificial aid, when it 
was discontinued. 

The child began to walk when sixteen months of age, with 
the feet perfect in form and development. 

The photograph, Fig. 45, taken April, 1868, five years after 
all treatment was suspended, shows how well the feet are devel- 
oped, and the perf ectness of the recovery. 

Case. Congenital Talipes Equino -Varus ; Tenotomy per- 
formed Three Times without Relief of the Deformity ; Perma- 
nently relieved oy India-rubber Muscles and Electricity. — Walter 



104 TALIPES. 



C, aged three, New York City, was brought to me, May 17, 
1863, for well-marked talipes varus, which was congenital. The 
mother stated that " at birth the left foot was much smaller than 
the right, and was almost without any heel ; the whole leg was a 




Fig. 45. 

little smaller than the right ; and that the sensation of the limb 
was very imperfect, but never entirely absent." The note of 
treatment at that time in my record-book is: "I divided con- 
tracted muscles (ten do- A chillis and tibialis anticus), and brought 
the foot into position by adhesive straps. Progress rapid and 
result satisfactory." 

I had divided the muscles, having full faith in the necessity 
of this treatment. The deformity was reduced readily, but, as 
will be seen, the true disease was not removed, and consequently 
the deformity returned. 

May 22, 1867. — The boy returned, being then seven years old. 
Tenotomy had been performed three times in all, but with no 
satisfactory result, although he had worn a variety of club-foot 
shoes. The foot was much smaller than the other, as was also 
the leg. When standing, the foot became almost completely in- 
verted, and the heel drawn up, the weight coming upon the dor- 
sum of the foot, just behind the little toe, and the one adjoining, 
near the metatarso-phalangeal articulation, at which place was a 
large callosity, which was very tender. The astragalus was sub- 
luxated forward, and could be distinctly felt in front of the tibia, 
making a serious deformity. 

The foot could be quite readily brought into an almost natural 



CASE. 105 

position, with only a moderate amount of force, showing conclu- 
sively that the deformity was one from paralysis, and not depend- 
ent upon any abnormal contraction. 

I applied the India-rubber tubing on the outer side of the leg 
— according to the plan of Mr. Barwell — and the foot was almost 
immediately brought into its natural position. By a very slight 
addition to the thickness of the heel and sole of his shoe, to 
equalize the length of the limbs, he walked almost naturally in a 
very few days. 

He was directed to run around as much as possible, and to 
have electricity applied over the peroneal muscles ten to fifteen 
minutes daily. 

July 1st. — The mother states that after three or four weeks the 
leg and foot had so much increased in size that she had to get a 
larger shoe. Readjusted the bandages, and applied new plaster. 
Continue treatment as before. 

September 1st. — Has improved so much that, when all the 
bandages and India-rubber are removed, he can slightly evert and 
flex the foot by making a strong effort to do so. I ordered a 
well-fitting shoe, with a steel spring on the outer side to run up 
the leg, with a hinge at the ankle-joint, and a rubber spring 
sewed fast opposite the little toe, and secured to a chain at the 
top of the steel spring, near the head of the fibula. 

January 1, 1868. — He has improved so much that he can 
tread flat upon his foot without any assistance. I therefore took 
off the steel support and rubber spring. 

His foot and leg are well nourished, and very much increased 
in size. The sole and heel require about one-fourth of an inch 
more than the other shoe, to equalize the length — otherwise 
there is no deformity. 

October 31, 1868. — Boy has not been seen since last entry till 
now, as he has been away from the city. Has given up the use 
of the elastic shoe, and has been wearing an apparatus consisting 
simply of a firm iron sole, with no joint, which is too narrow 
for the foot, and a stiff upright bar, jointed at the ankle, which 
is fastened about the calf. This change in treatment has hin- 
dered the progress of the cure. The skin is warm and of a good 
color, but the muscles are weak. In walking, he is unable to 
evert the little toe, and allows the weight of the body to fall upon 
the outer edge of the foot, thus endangering a relapse. The cure 



106 



TALIPES. 



is, however, so well advanced, that I think an ordinary neatly- 
fitting, broad-soled shoe, with an upright bar, and a rubber for 
everting the foot, similar to that shown in Fig. 59, will be suffi- 
cient for its completion. 

Since the above date Walter C. has again called at my office. 
The cure is now perfect, the sole of the foot coming flat upon the 
floor without any artificial aid. The leg has grown to very near- 
ly the same size as the sound one. 

Case. Talipes Calcaneo - Valgus Paralytica / Cure by Elastic 
Extension.— May 4, 1867.— G. B. M., aged three, New York City. 
During dentition the child suddenly lost the use of his lower 
limbs. He was unable to stand. His dorsal muscles were so 
weak that he had to be propped up in a sitting posture. After 
the expiration of three weeks he began to creep, dragging his 
body. A weight was then attached to each foot. After 
two months he was able to stand, when it was noticed that his 
right foot had less power than the left. The toes were elevated 
and turned outward, and the heel depressed. In March, 1866, an 
upright support was made for his leg, and elastic extension ap- 




Fig. 46. 



plied in the popliteal space, to take the place of the gastrocnemius. 
He has worn this above a year. He is able to walk well with a 
boot on ; but when it is removed there is no improvement upon 
the condition existing before treatment. There is no tendo- 
Achillis visible ; the anterior muscles are very prominent ; the 
heel is atrophied, and the internal malleolus displaced. {See Fig. 



CASE. 



107 



46.) Artificial muscles were applied, after the manner of Mr. 
Barwell, over the gastrocnemius and tibialis-anticus muscles. 

Fig. 47 shows the condition after the use of the rubber 
muscles, galvanism, and strychnia hypodermically, from May to 
September. 




Fig. 47. 



Case. This case shows very well the effect of only a few 
hours' tension on the distorted feet, particularly the left one. 
Fig. 48, from photograph, shows his condition at time of 





Fig. 4S. 



Fig. 49. 



application of dressing. Fig. 49, also from photograph, shows 
the result after only three hours' application. 

The India-rubber springs were worn with the tin splint and 
adhesive plaster, as seen in Fig. 49, for two months. 



108 



TALIPES. 



After this time he wore the improved shoe with ball-and-socket 
joint, which answered mnch better, as the spring from the back 
of the heel to the little toe materially aided in everting the feet, 
and when this was properly adjusted he could walk remarkably 
well. 

This boy went to the country, and I lost sight of him ; and I 
am therefore unable to tell the ultimate result of the treatment 
in his case ; but I hear that he recovered perfectly in less than 
two years. 

Case. Congenital Varus of Right Foot, and Varo- Calca- 
neus of Left Foot, cured by Elastic Tubing. — John F. C, 432 
Second Avenue, aged six months (Fig. 50), was brought to the 




Fig. 50. 



out-door department of Bellevue Hospital, November 7, 18'67, 
under care of Dr. W. H. Young. Parents healthy ; no other 
children. Treatment by elastic tubing (see page 00). The right 
foot was dressed November 11th, the foot being quite easily 
brought round and retained in the straight position. November 
15th, dressings have given no pain or uneasiness to the child. 
Reapplied by Dr. Sayre. 

20/A. — Deformity of right foot about one-half ; dressings ap- 
plied to left foot to-day, which is retained in position by a very 
small amount of elastic force. 

The dressings were reapplied about once a week, until Janu- 
ary 2d, when they were removed, the feet being nearly in the 
normal position, and easily retained in a straight position by a 
common pair of laced boots. The India-rubber will be reapplied 
as soon as the child commences to walk, if necessary. 

The photograph, Fig. 51, showing the improvement, was 
taken April 8, 1868. 



CASE. 



109 



Case. Double Talipes Equino - Varus treated by Section 
of Plantar Fascial and Elastic Extension • Section of Integu- 
ment ultimately required. — July 22, 1867. — Annie L. W., aged 
three and a half years, New Jersey. The deformity is congeni- 
tal, and is attributed by the father, a physician, to " a fright of 
the mother at a deformed cripple while the babe was in utero" 
"When three months old the child was brought to me. I then 




Fig. 51. 



succeeded in bringing the feet nearly into their proper position 
by handling, and then applied a leather splint, as described in 
Lecture X. The father continued the treatment for three months, 
with benefit. He then entered the army, and the treatment was 
changed for another plan. During the last eight months the child 
has been treated by a fixed modification of Scarpa's shoe, which 
caused ulcers upon the dorsum of both feet, and the condition 
has become worse rather than better for the treatment. The feet 
are now strongly inverted, and the plantar fasciae firmly contract- 
ed. She walks by separating her feet as far as possible, and tak- 
ing short, awkward, waddling steps. On the sides of the feet 
are scars of former tenotomy. On each dorsum is a cicatrix of a 
large ulcer, caused by treatment, which, I fear, seriously compli- 
cates the treatment of the case. 

July 22, 1867.— Cut both plantar fasciae. The feet were then 
bound down to thin board-splints. 

August 6th. — Applied two rubber muscles to right foot, one 
to the left. In less than an hour she began to run about the 
office. 

20tk. — Has much improved. Only suffering complained of 
is the pressure of the plaster on the callus produced by the shoes 



110 TALIPES. 

formerly worn. Readjusted plasters, so as to relieve the diffi- 
culty. 

December 17, 1868. — The father again brought the child to 
my office. He complains that for some reason the eversion of 
the feet is still painful : the child has defeated the treatment by 
turning her feet in such a manner as shall bring the outer edges 
upon the ground, by that means relaxing the strain upon the 
plantar fasciae ; when this manoeuvre fails, she forcibly inverts 
the feet with her hands. Examination showed the fasciae to be 
tense and contracted, reunion having taken place. Accordingly, 
the child being under chloroform, I cut the plantar fasciae, but 
the deformity did not yield, the integuments having become con- 
tracted and rigid. I accordingly made an incision about an inch 
long, and brought the foot into position. The straightening of 
the foot caused the edges of the wound to separate about three- 
fourths of an inch. 

Since this last operation the father reports the progress as 
perfectly satisfactory. 

Case. — S. S., Brooklyn, aged seven, was born with double 
club-foot, according to the mother's statement ; was operated upon 
when three months old by a surgeon in this city, who cut the 
tendo-Achillis of both sides ; a few months afterward the tendons 
of both anterior tibials were cut, and about two years since the 
tendo-Achillis was cut again. Shoes of different kinds had been 
worn all the time, and at last the surgeon had abandoned the case 
to Mr. Ford, the instrument-maker, who brought the child to me. 

The feet at the time were secured in shoes with a firm steel 
sole, and, although they had, opposite the ankles, joints in the 
rods running up the legs, which were acted upon by screws, and 
intended to elevate the feet, still, as they were only moved when 
the attendant applied force to the screw, and then fixed in the 
position obtained, the muscles of the leg, even the normal ones, 
from being so long in a passive condition, had become atrophied ; 
and his legs, from the ankle to the knee, were more like two 
straight sticks, or nearly equal in size at top and bottom, than like 
an ordinary leg with well-developed muscles. 

When the shoes were well adjusted, he could walk by the aid 
of canes, on the outer corner of the little toes, for a little distance, 
the feet crossing over each other ; but the pain was so great that 
in a few minutes he would give up his exercise, and could not 



CASE. 



Ill 



again be induced to walk until the shoes had been removed, and 
the feet allowed to rest. 

When he attempted to walk without the shoes his feet dropped 
and were inverted, so that he walked upon the outer part of the 
foot, where there was an extensive callus. (See Fig. 52.) 

On the 27th May, 1S6S, Dr. L. M. Yale put the child under 
chloroform, when I found that by moderate force I could bring 
the left foot into nearly a natural position. 

On the right side, the heel could be brought down to a natural 
position, but it was impossible to elevate the foot, or rotate it 
outward ; in fact, the whole anterior part of the foot seemed like 
a solid plaster-cast, with no motion at any of the joints, except 
the toes. 

I therefore made a free subcutaneous section of all the resist- 
ing structures in the hollow of the foot, closed the wounds with 
adhesive plaster and a roller, and immediately brought the foot 
almost straight. It was secured in this position by a board under 
the foot, and a roller, as indicated above. 

I directed Mr. Ford to make a pair of shoes, with orbicular 





Fig. 52. 



Fig. 53. 



joints in the soles, and rubber elastics to elevate the foot and 
rotate it outward, as I have already described, and to return with 
the child when the shoes were completed. 

He returned on the 10th of June, thirteen days after the op- 



112 • TALIPES. 

eration. The wounds had partly healed without suppuration, 
and the child had suffered very little pain from the operation. 
The bandage had been removed once or twice by my assistant, 
and the foot well washed and rubbed. 

Mr. Ford had constructed the shoes remarkably well, from 
the model I had given him. They were put upon the child, and 
fulfilled all the indications desired most admirably. The rubber 
was hooked on with only a very moderate tension at first, but this 
was gradually increased a link at a time for an hour or more. At 
the end of about three hours his feet were in a perfectly natural 
position, and he could walk without a cane, with his heels upon 
the ground, and his feet parallel with each other. He walked to 
the photograph-gallery without assistance, and had his picture 
taken (see Fig. 53), thirteen days from the operation. 

Electricity was applied to the anterior portion of the leg and 
foot every other day, and very free handling and motion made to 
all the joints of both feet. 

June 20, 1868. — He can flex his feet slightly without the aid 
of the rubber ; his feet are much warmer, more natural in color, 
and the legs have increased around the calf nearly three-quarters 
of an inch in circumference. 

January 1, 1869. — The improvement has continued up to the 
present time. The mother has applied faradism, frictions, and 
has manipulated the feet daily with great care, and the result has 
been a perfect cure. 

Case. — H. F., Hudson, New York. A girl four years of 
age was sent to me to divide the tendo-Achillis for club-foot of 
the right side. The history of the case as given by the mother 
was, that the child presented as a " cross-birth," and was delivered 
by the doctor by turning, and the deformed foot was the one 
seized by the doctor in the delivery ; and, in the opinion of the 
physician who delivered her, the foot was injured at the birth. 

When the child was old enough to walk, this foot was found 
to drop in front, the ankle was stiff, " and the heel seemed to be 
pinned to the back of the leg." " Dr. Taylor's Swedish move- 
ment-cure " was tried for two years, but with no result beyond 
making the ankle more flexible. 

When the foot is permitted to hang in its natural position, 
there is a remarkable protuberance of the astragalus, as seen in 
Fig. 54, which was traced from her leg. By taking hold of the 



CASE. . 113 

foot, however, with a very slight force the tendo-Achillis could 
be stretched, and the heel easily brought down to its natural 
position, at a right angle with the leg, as seen in the dotted lines. 



Fig. 54. 



But the foot, in front of the medio-tarsal articulation, still 
drooped, as seen in Fig. 54, and could not be elevated. 

In my note-book I find the following entry, made at the time 
of my first examination, by my assistant, Dr. Yale : " It is quite 
possible that the plantar fascia and short flexors of the foot will 
require division, but shall at first attempt to accomplish the res- 
toration of the foot by manipulation, and shoe with elastic exten- 
sion." The result of the treatment proved the wisdom of this 
decision. 

I put her under chloroform, and by very firm pressure and 
extension, continued for some time, I found that I could make a 
very decided diminution of the arch in the hollow of the foot, 
and very materially increase its length • and, as I never cut tis- 
sues that will stretch under a moderate degree of force, I resolved 
to use the shoe, without resorting to tenotomy. 

The foot was handled with great freedom every day while the 
shoe was being made, and stretched as much as the child could 
bear without suffering much pain ; and electricity was applied to 
the anterior muscles of the leg every other day. 

On the 24th of June, the photograph (Fig. 55) was taken, 
and then an ordinary shoe with steel supports on either side, 
jointed opposite the ankle, and buckled around the leg above the 
calf, to give attachment to a rubber elastic which ran from a 
stirrup over the ball of the toes, for the purpose of elevating the 
foot, was applied, and the photograph (Fig. 56) was taken about 
one hour afterward. "With this shoe on, and the rubber proper- 
8 



114 



TALIPES. 



J j adjusted, she runs with perfect freedom, and without the 
slightest limp. 

October 31, 1868. — A slight inversion of the toe remains. 





Fig. 55. 



Fig. 56. 



Ordered a ball-and-socket shoe in order that the eversion muscle 
may be applied. This corrects the inversion perfectly. 

Case. Talipes Plantaris, Section of Plantar Fascia, Plex- 
ors, and subsequently the Integuments ; Elastic Extension ; Cure. 
— Miss N., of Georgia, aged twelve, gives the following his- 
tory : "When sixteen months old she had an attack of convulsions, 
and another four months later. Soon after, the left foot was no- 
ticed to be contracted ; or, as the mother expresses it, " she was 
pigeon-toed when her weight came upon the foot." For a short 
time she wore some sort of a club-foot shoe, but soon abandoned 
it. ~No treatment beyond liniments was employed, until October, 
1865, when, in accordance with the advice of several surgeons, 
the tendo-Achillis was cut, and the treatment continued by apply- 
ing a very stiff club-foot shoe. Eo material benefit followed the 
operation. The deformity increased, till, in the winter of 1867- 
'68, it was so far advanced that, in walking, the toe alone touched 
the ground. In May, 1868, the tendon of the extensor proprius 
pollicis was cut, with the expectation of relieving the deformity. 
This hope was not realized, the difficulty in walking being greater 
than ever. The parents accordingly brought the child to this 
city, to Prof. W. H. Van Buren, who sent the case to me. 

July 29, 1868. — The position of the foot, when no weight is 



CASE. 



115 



upon it, is as in Fig. 57 ; when, however, the child attempts to 
walk, the position becomes as in Fig. 58. The great-toe is semi- 
luxated by the pressure falling directly upon the ball of it. 

Under chloroform I cut the plantar fascia and short flexors of 
the foot, and fastened the foot to a board. The patient went out 





Fig. ot 



Fig. 58. 



of town for a few days, and the foot was not properly attended to. 
The wound did not unite by first intention, but a slight amount of 
suppuration followed. 

August 17th. — The foot still resisted attempts at straighten- 
ing. I accordingly divided the integuments in the sole of the 
foot, forcibly pressed the tarsal bones into proper position with 
the hand, and broke up the adhesions in the sole of the foot. 
The foot was then firmly bandaged to a board with a large com- 
press of wool over the instep. The operation was followed by 
some febrile reaction, which had disappeared on the following 
clay. 

September 1, 1868. — The progress has been uninterrupted 
since the last operation ; though the wound in the sole is not en- 
tirely healed, she is able to have the shoe with the jointed sole 
applied, and to walk in it without pain, the heel being clown and 
the foot in a natural position. Since the operation the foot is 
about one and a half inch longer than before. 

17th. — Recovery perfect. She everts and flexes the foot 
voluntarily. In walking, she wears an ordinary lacecl boot, with 



116 



TALIPES. 



a single rubber muscle from opposite the little toe to one of the 
upper eyelet-holes. (See Fig. 59, from a photograph). 




Fig. 



Case. Talipes Plantaris, or Cavus, Traumatica, with Dis- 
location of Tarsal Bones, of Eighteen Years' 1 Standing ; Oper- 
ation ; Treatment by Elastic Extension; Cure. — September 1, 
1868. — Miss F., aged twenty-five, New York City. When about 
seven years old she injured her right foot by jumping from the 
seat of a high wagon to the ground. The injury was sufficient to 
cause severe pain for a time. After the disappearance of the pain 
the foot was neglected for two or three years, but, after the lapse 
of this time, surgical care was demanded. The physician in 
attendance cut the tendo-A chillis. He proposed section of the 
plantar fascia, but, for some reason, it was not made. From that 
time she was able to walk tolerably well until between three and 
four years ago, when, she having adopted a sedentary occupation, 
the foot became painful in walking, and the ankle, which had 
always been weak, frequently turned under her weight. She 
attributes this change to a failure of ^strength from confinement 
in-doors, rather than to a progressive contraction of the foot. 

The sound foot is eight inches in length, the diseased one is 
so shortened (see Fig. 60), by the contraction of the sole and ele- 
vation of the toes, that but ^ve inches rest upon the ground. 
The calf of the sound side is twelve and a quarter inches in cir- 
cumference, that on the injured side ten and a half inches. The 
limbs are of the same length. 

After anaesthetizing the patient, the deformity was reduced 



CASE. 



117 



by cutting the plantar fascia and then forcing the projecting bone 
as a wedge down between the adjoining bones. To accomplish 
this, very considerable force was required. The wound of the 
skin in the sole was tightly closed, as described above when 




Fig. 60. 



speaking of tenotomy. The foot was secured in proper position 
by bandaging it strongly to a board padded with cotton. The 
foot was now seven inches on the ground, instead of five. Dr. 
J. C. Nott assisted me in this operation. 

September 12th. — Applied ball-and-socket shoe, lacing in front, 
and with a slight heel. 

20th. — The patient having returned to her work, the foot has 




Fig. 61. 



troubled her considerably, owing to tenderness over the tarsus. 
The force required to reduce the bones to proper position ap- 
pears to have caused a slight periostitis, which is reexcited by 



118 



TALIPES. 



any attempt at walking. Rest for a week, with cold and seda- 
tive lotions, were accordingly directed. The result was perfectly 
satisfactory. Ordered to manipulate the foot with the hand. 

January 1, 1869.— The foot has improved so much that the 
club-foot shoe is no longer necessary, an ordinary, neat-fitting, 
laced boot sufficing to keep the foot in its normal position. Fig. 
61 shows the condition of the foot. 

Case. Talipes Varus Paralytica, acquired, of Five Years' 
Standing / Unsuccessful Treatment by Tenotomy; Subsequent 
Treatment by Elastic Extension successful. — September 9, 1868. 
— Harry M., aged seven, New York City. Until two years 
of age was perfectly well. At that time he suffered from a 
severe diarrhoea, and during the course of the disease was sud- 
denly seized with paralysis of both upper and lower extremities. 
After about two months he recovered the use of his arms and of 
his left leg. The peroneal muscles of the right leg remained 
paralyzed, and are still so, a marked talipes varus being the re- 
sult. 

In 1865 the family physician cut the tendo-Achillis, the tendon 
of the tibialis-anticus, and the plantar fascia, and applied a fixed 
club-foot shoe, which allowed no motion to the foot. The result 





Fig. 62. 



Fig. 63. 



was negative. The condition of the foot at the present time is 
shown in Fig. 62. 

I applied the ball-and-socket club-foot shoe, with rubber 
muscles, for fiexion on the fibular side of the leg, and for eversion 
of the foot. Figs. 62, 63, and 64, are from photographs taken 



CASE. 



119 



at the same visit to the photographer's. Fig. 62 exhibits the 
deformity. Fig. 63 shows the shoe adapted to the foot (not the 
foot to the shoe), and Fig. 64 the restoration of the foot to its 
normal condition, after the rubber muscles were attached. 

In addition to wearing the shoe, frictions and electricity have 
been applied to the leg. 

January 9, 1869.— The progress toward cure has been steady. 
The calf of the paralyzed leg has increased about an inch in cir- 





Fig. 64. 



Fig. 65. 



cumference since the commencement of treatment. The power 
over the muscles has increased, so that he can voluntarily flex the 
foot, although he is still unable to evert it. 

January 22d. — The condition of the case is shown in Fig. 65, 
from photograph by O'Neil. 

Case. Congenital Douhle Talipes Varo - Equinus / Tenoto- 
my ; Reduction of Dislocated Tarsal Bones by Force. — Herbert 
F. C, aged ten, Massachusetts. The mother thinks the deform- 
ity due to the fact that, about the second month of pregnancy, 
she sat in a cramped position for some hours, and, from that 
time till the birth of the child, was impressed with the idea that 
the child would have deformed feet. When eighteen months old 
he was placed under treatment. Since that time he has worn 
constantly orthopedic shoes of one sort or another. They have, 
however, always been stiff and fixed. At present the deform- 
ity is so great that he can with difficulty stand alone without 
artificial support. Calves, nine inches and seven and a quarter 



120 



TALIPES. 



inches. His gait is very labored and clumsy. The plantar fasciae 
and the short flexors of the feet are tender when put on the 
stretch, as also are the tendons of the solei muscles. The head 
of the astragalus and anterior extremity of the calcaneum are pro- 
truded to a remarkable extent (see Fig. 66, from photograph.) 




Fig. 66. 



November 16, 1868. — Before the class at Bellevue Hospital, 
anaesthetized the patient, cut the tendones-Achillis, plantar fasciae, 
and the short flexors. By exerting great force upon the tarsal 
bones with the hands, they were forced down into their proper 




Fig. 67. 



places. The soles of the feet were fixed to boards and the feet 
properly padded and very firmly bandaged. 

December 9, 1868.— There has been no disagreeable result from 



CASE. 



121 



the force employed. The boy walks very well with the ball-and- 
socket shoe. The feet are very nearly in normal position. 

Fig. 67 shows the change which had taken place, January 20, 
1869, from photograph by Mason. 

Case. Double Talipes Varus, congenital; treated by Neil's 
Plan, later by Adhesive Plaster, and by BarweWs Method.— 
November 5, 1868.— A. J. K., aged three weeks, New York City. 
Has double congenital talipes varus. The position of the feet is 
as in Fig. 68. Applied the dressing of Dr. Henry Neil (Fig. 40). 





Fig. 68. 



Fig. 69. 



November 10th. — The treatment has straightened the feet con- 
siderably, but the child has cried so much that the mother removed 
the dressing. Accordingly, November 14th, the adhesive-plaster 
dressing (Fig. 43) was applied. This was worn for two or three 
weeks, when it became loosened. The mother neglected to come 
to the office again, and the child went without treatment for 
several weeks. 

January 9, 1869. — Applied Barwell's dressing. 

19th. — Kesult was very satisfactory. Position as in Fig. 69. 
The inner edges of the two feet can be placed in apposition from 
heel to toe. 

The following case of acquired talipes, the result of spinal 
meningitis, is of some interest, as illustrating the existence in the 
same patient of the most intense hyperesthesia of the cutaneous 
surface and perfect or complete motor paralysis at the same time : 



122 TALIPES. 

Case. — Miss Hattie B., aged twentj-two. Was always ro- 
bust and very active until December, 1868, when, in Stuttgart, 
Germany, she contracted typhoid fever during an epidemic. Can 
get but little account of this illness, save that it lasted many 
weeks, during much of which time the patient was in a state of 
low delirium, and later she was too weak to take much notice of 
occurring events. When she first recollected herself after the 
fever, all power over her limbs was gone. She could not even 
move a single toe on either foot, and could not lift a fork or spoon 
from the table. She had extensive bed-sores on the heels, over 
the sacrum and trochanters. 

At this time the cutaneous surface of the whole body was so 
exceedingly sensitive as to cause her great agony when touched 
or rubbed, even in the lightest manner. 

In August, 1869, her mother went to her, and found her suf- 
fering chiefly from the trouble which still in part remains, viz., 
contractions of the lower limbs with hyperesthesia. Her knees 
at that time were very rigidly extended ; the lower limbs, espe- 
cially the feet, were excessively sensitive, the weight of a sheet 
being too much for her to bear. 

The feet after washing could not be dried with a towel, raw 
cotton being used instead, and even this would cause an involun- 
tary- shudder as it touched the skin. Under the treatment at 
Stuttgart, the knees partly regained their mobility, the hyperes- 
thesia diminished, and the position of the feet was somewhat im- 
proved. 

After her return to this country, Dr. Barber, of Leroy, 'New 
York, practised manipulations of the feet with the hope of di- 
minishing the distortion, which is that of talipes equino-varus, 
with a strong curve on the edge of the plantar fascia. 

Dr. Barber improved the position of her feet somewhat, but, 
not being satisfied with the progress of the case, sent her to me 
in July, 1870. 

The manipulations were continued for some weeks, but the 
sensibility was too great to allow of the exertion of much force ; 
in fact, you could scarcely touch the feet, or rub the skin in the 
lightest manner possible, without causing her to scream with 
agony. The deformity could not be rectified, even under full 
anesthesia. 

September 30, 1870. — The position of her feet is as seen 



CASE. 



123 



in Fig. 70, from drawings by Dr. L. M. Yale, made at the 



time. 



She was placed fully under chloroform, and I divided the 
tendo-Achillis and plantar fascia of the left foot, and was then 




Fig. 70. 



compelled to divide the skin also before I could restore it to po- 
sition. The foot was then dressed with adhesive plaster and a 
board (see Fig. 43). When the effects of the chloroform had 
passed off, she complained of great agony, although a full dose 
of Magendie's solution had been given at 4 p. m. At 6 p. m. 
repeated the morphine. This being the first and only case where 
continued pain has followed the operation, I have reported the 
daily notes of the case as taken at the time by Dr. Yale : 

October 1st. — Continues to complain greatly ; has not slept ; 
gave bromide of potassium without effect. 

2d. — Some relief, due probably to the foot having slipped in 
the dressing. Fifteen-grain doses of hydrate of chloral seemed 
to produce better effect than morphine, to which latter she had 
become accustomed during her last illness. After her return to 
this country, she had great difficulty in breaking up the habit. 

4dh. — Dressed foot. At base of little toe an ecchymosed spot 
looking likely to slough. Lessened the strain of the adhesive 
plaster. 

6th. — Dressing very inconvenient ; a simple side-strap substi- 
tuted. Begins to have some appetite, but has constant chilly 
sensations. 

10th. — Has been sitting up for past few days. Could bear 
pressure on foot much better. Allowed wound in sole to close. 
The tendo-Achillis wound has also united. 



124 



TALIPES. 



11th. — Had last evening, at 10 p. m., a severe chill, lasting 
an honr and a half, followed by fever and delirium ; attempted 
to get out of bed. Delirium continued through the day ; pulse 
120, respiration 43. ~No signs of pneumonia, or any internal 
inflammation. Gave spiritus Mindereri and spirits of nitre; 
liquor potassse arsenitis. Foot looks all right ; no sign of trouble 
except the bruised spot under little toe, from, pressure of the 
board. 

12^A, 9 a. m. — Pulse 120, respiration 29. Erysipelatous 
blush running up left leg, and the back and inside of left thigh. 
Opened wound ; found no confined pus ; lips had granulated un- 
der the scab. Poultice to foot. 

p. m. — Met Dr. Clymer in consultation. Pulse 118, respira- 
tion 29. Temperature under right thigh, 103^-° ; under left 
(erysipelatous), 104°. To take hourly one grain of sulphate of 
quinine ; one-half drop Fowler's solution ; nitras argenti locally. 
Food, every two hours, milk and broth. 

The fever continued until October 28th. The highest temper- 
ature (under sound thigh) was 103°. 8. Remissions below 100° 
occurred 12th p. m., 16th a. m., 19th a. m., 23d a. m., 24th p. m., 
28th p. m. On the 17th the erysipelas became migratory in char- 
acter, and diminished in severity. The ecchymosed spot on the 
little toe was opened on the 15th, and discharged a little pus, 




■V- 



ferx 



Fig. 71. 



Fig. 72. 



from which time she began to recover. On the 23d there was 
an eruption of sudamina ; on the 24th, over back ; and notes an 



CASE. 125 

eruption, very much resembling scarlatina, absent from the ante- 
rior surface of the body. This lasted until the 29th. From this 
time she convalesced slowly, and, after some time, the manipula- 
tions of the foot were again resumed, and resulted, in about six 
months, in producing a very useful and nearly normal foot, as 
seen in Fig. 71. 

The operation had been attended with so much danger, that 
I refused to operate upon the other foot until her general health 
could be improved. She, therefore, left the city for Leroy, New 
York, where she remained for two years, getting around on her 
crutches, and bearing her entire weight on the " Sayre " foot (as 
she called it) without any pain ; but the other foot was entirely 
useless, and very painful on the slightest pressure. 

She returned in May, 1873, much improved in general health, 
with her left foot as seen in Fig. 71, and the right one as seen in 
Fig. 72. 

May 19, 1873, she was put under chloroform by Dr. Yale, 
and I divided the tendo-Achillis, and cut the plantar fascia, and 
dressed the foot with the board and adhesive plaster (see Fig. 43), 
with an additional plaster around the foot, and drawn firmly 
upon the outside of the leg. An injection of morphine was ad- 
ministered hypodermically. In the evening the patient was very 
comfortable, and declined taking any more morphine, on account 
of the difficulty she had formerly experienced in breaking up the 
habit. 

June 18th. — Dressing was removed ; had been on twelve 




days ; all the wounds entirely healed, without pus. The instep 
was a little bruised, but no slough. The foot very much improved 



126 



TALIPES. 



in position ; heel comes down to the floor without pain. She is 
able to flex the foot voluntarily. There is some inversion of the 
foot, which is retained in position by adhesive straps. 

24:th. — Much improved ; she is able to walk a little by the aid 
of a chair. 

From this time she improved rapidly ; was able to have her 
feet shampooed and rubbed freely without pain, and on July 1, 
1873, was able to walk in an ordinary shoe. The feet are both 
shorter than natural, and thicker at the ball, on account of the 
contraction of the toes ; but she is able to walk without assist- 
ance, with both feet naturally upon the floor, as seen in Fig. 73. 

The following case shows what can be done to rectify the 
deformities of the part by very simple means, if applied at an 
early age : 

Case. — A son of J. H. B., aged seven months, 16 East Third 
Street, was sent to me by Dr. J. P. Lynch, February 1, 1870, 
with congenital talipes varus of the left foot. {See Fig. 74.) 





Fig. 74. 



Fig. 75. 



After manipulating the foot for about one hour, as already 
described, the foot was dressed with adhesive plaster and a roller, 
and retained in its natural position without any difficulty. {See 
Fig. 75.) Both from drawings by Dr. L. M. Yale, and both 
drawings made within two hours of each other. 

These dressings were changed from time to time as occasion 
required, and, when the child was old enough to walk, a slight 
rubber elastic from the outer toe of the shoe to the garter was all 
that was required to guide the foot to its normal position. Gal- 



CASE. 127 

vanism, friction, and shampooing, were continued until the child 
was two years old, when the -cure was complete, and remains so. 
(See Fig. 76.) 




Fig. 76. 

The following case shows what can sometimes be done, even 
in the worst form of talipes, by intelligent and persevering effort, 
without tenotomy, although the treatment was carried out entire- 
ly by the father (a non-professional man) after only two practical 
lessons as to the principles involved in the treatment of paralytic 
cases : 

Case. — Harry B., aged one year, was sent to me on Decem- 
ber 29, 1869, by Dr. G. W. Hodgson, of White Plains, New 
York, with the statement that he had been under treatment in 
an orthopedic institution in this city, by his advice, since he 
was eleven weeks old ; but, finding no improvement, he had ad- 
vised them to bring the child to me. He had been wearing club- 
foot shoes with stiff soles and an iron brace up the legs all the 
time, with no other result than producing a number of callosities 
on the feet, which were quite sore and inflamed. In consequence 
of the pain inflicted by the shoes, they could only be worn a very 
short time, and had to be removed several times a day. 

As soon as the shoes were removed, and the child made to 
stand, the feet assumed the position as seen in Figs. 77 and 78, 
from photographs by O'Neil, December 29, 1869. 

After manipulating the feet a short time, I found that they 
could be brought very nearly into their normal position without 
tenotomy, and, finding them to be of paralytic origin, I therefore 
dressed them after " Barwell's method," as previously described. 

In referring to my case-book, I find the following, and the 



128 



TALIPES. 



only entry in connection with this case : " February 1, 1870.— 
Redressed ; progressing favorably." From this time I lost sight 
of the case entirely, and never saw him nntil June 21, 1873, when 
his feet were almost perfect, as will be seen in Fig. 79, from a 





Fig. 77. 



Fig. 78. 



photograph sent to me by the father with the following letter in 
answer to one from Dr. Hodgson inquiring as to the result of 
treatment in the case. 

At the second visit, February 1, 1870, the father stated that 




Fig. 7 



he had already spent so much money on the child that he could 
not afford to go on with the treatment, and I therefore took great 
pains to instruct him as to the application of the plaster and 
" rubber muscles," and also the proper manipulations to be given 
to the feet, and trusted to his ability to carry on the treatment. 

The result is seen in Fig. 79, from a photograph sent by the 
father, with the following letter, dated 



CASE. 



129 



" Amenta, Dutchess Cotnty, June 10, 1S73. 

"De. L. A. Sayee— 

"Deae Sie: I send you a photograph of Harry's feet, and am so proud 
to think you have asked for one ! 

"Little did I think they would ever be made so perfect! I have done 
just as you told me to do from the first, and have worked night and day to 
do it. You have acted like a father to the little fellow, and, by your skill 
and good treatment, they are about perfect, except a little crook in the toe. 

" Gratefully yours, etc., 

"B. T. B." 

Had the father applied the plaster nearer the toe, the small 
def oraiity still remaining could have been easily corrected ; but 
he simply applied it as he had seen me do it on the first visit, 
and made no change in his points of attachment for the artificial 
muscles as the cure progressed, as he should have done. As the 
case illustrates a very important practical point, I have thought 
it worth recording, to impress upon the student and physician 
what can be accomplished by constant care and attention, and the 
application of a continuous elastic force properly applied. 

The following case, though not so great a deformity, illus- 
trates the same principle of treatment, and the success that can 
be obtained by the constant care of non-professional attendants, 
if they are only properly instructed : 

Case. — Catherine M., Susquehanna, Pennsylvania, aged seven- 





Fig. 81. 



teen days, was brought to my clinic at Bellevue Hospital in Sep- 
tember, 1870, with congenital talipes equino-varus of both feet, 
of paralytic origin, as seen in Fig. 80, from photograph taken at 
the time by Mason, photographer to Bellevue Hospital. 
9 



130 TALIPES. 

After manipulating the feet a short time, and being satis- 
fied that the deformity was of paralytic origin, I dressed them 
with Neil's foot-board, in order to show the class its mode of ap- 
plication. (See Fig. 40.) 

This was used some three weeks, without any marked im- 
provement, and " Barwell's " dressing, with India-rubber muscles, 
was substituted in its place, and the mother returned with the 
child to her home in Pennsylvania. 

The mother took entire charge of the case from this time, 
changing the plasters as occasion required, and moving their po- 
sition according to instructions as the child's feet became more 
straight. The plaster and rubber muscles were worn until the 
child was able to walk, when she applied my improved club-foot 
shoe, which she wore until the spring of 1873, when she was per- 
fectly cured, as seen in Fig. 81, from photograph by O'Neil, taken 
March 21, 1873. 

In looking over my note-book, I find a number of cases very 
similar to the last two here described, and that have terminated 
with the same fortunate result, by following the treatment above 
recommended ; and I can, therefore, speak of it with confidence. 

It frequently happens, in bad cases of varus and varo-equinus, 
that after we have restored the foot to its normal shape, either by 
the constant use of elastic tension, or by tenotomy of the tendo- 
Achillis and plantar fascia combined with elastic tension, as the 
case may be, that the foot, although perfect in shape, cannot be 
held in the proper position, but will remain inverted on account 
of the paralysis of the rotator muscles of the thigh : and, to over- 
come this deformity, it becomes necessary to evert or rotate out- 
ward the entire limb. 

To accomplish this object, Mr. Eeynders, 309 Fourth Avenue, 
New York, has recently constructed for me a shoe with the 
additional attachment of a rotating screw, which fulfills the indi- 
cations most completely. It is the application of the same prin- 
ciple which I have for so long a time used in the outward rotation 
of the femur in the third stage of hip-disease. 

In applying this force for the outward rotation of the foot, in 
cases of club-feet, a light metallic rod, or shaft, is secured to the 
bottom of the shoe, in front of the heel, passes up on the outer 
side of the limb, and connects with a well-padded pelvis-belt, A, 
having joints, of course, opposite the ankle, #, knee, E, and hip, £. 



SHOE WITH EVERTING SCREW. 131 

Just below the joint, opposite the hip, the shaft is divided into 
two sections, and at this point is an endless screw, G, placed trans- 
versely to the shaft. The screw is worked by a key, C, and is 
capable of producing rotation through two-thirds of the arc of a 
circle. F, is a well-padded belt, just above the ankle, and D, 
another belt above the knee. (See Fig. 82.) 




Fig. 82. 

The following case, for which the instrument was constructed, 
illustrates not only this point, but also another, which it seems 
important to bring more prominently forward, namely, the impor- 
tance of commencing the treatment of this class of deformities 
immediately after birth, as it will be seen that the position of one 
of the feet was perfectly rectified in a very short time, by simply 
placing it in the natural position, and using proper dressings. 
The other foot, which had undergone structural shortening, 
required section of the contractured tendons and fasciae before 
perfect restoration could be effected. 

Case. Congenital Varo-Equinus, Left Foot ; Varo- Calcaneus, 
Right Foot (as seen in annexed Drawing, by Dr. Yajle, Fig. 83). 
— January 2, 1874, 1 was called, at the request of Prof. Barker, to 
see the infant child of Mr. B., Eighteenth Street, aged four days. 

By manipulating his feet for half an hour or more, I was 



132 TALIPES. 

enabled to bring the right into its natural position, and the left 
one nearly so, without much trouble, and to retain them in this 
position, with the circulation restored. 

During the first efforts at restoration of the feet to their 
natural position, they would become ashy white, but the color 




Fig. 83. 

would instantly return on letting them go back to their original 
distortion. 

The left foot was retained as nearly in its normal position as 
it could be brought by a single piece of adhesive plaster around 
the foot, drawn up on the outside of the leg and secured by a 
flannel roller. 

The Tight foot had a piece of adhesive plaster placed on the 
plantar surface — drawing the heel up, and secured on the back of 
the leg; and another strip of plaster, to correct the varus, same 
as the left, and both secured by a flannel roller. No anaesthetic ; 
no crying ; no cutting. 

January 4dh. — Child very comfortable. Eenewed dressings, 
with friction. 

6th. — Child perfectly easy, and feet improved in position. 
Eeadjusted dressings. 

February 3d. — Dressings reapplied (same plaster being used) 
every two days until February 1st, when the dressings were 
entirely removed from the right foot, which was perfectly cured, 
the child voluntarily retaining it in its natural position ; but the 
left foot gave reflex spasm on point-pressure upon the tendo- 
Achillis and plantar fascia. However, on account of the removal 
of the child to the country, these tissues were not divided, but 
elastic tension was advised to be continued, in hope of benefiting 



SHOES FOR DOUBLE IXYERSIOX, 



133 



the child, and with the intention of cutting in the future, if found 
to be necessary ; and on — 

December 11, 1874, finding that point-pressure upon the ten- 
do-Achillis and plantar fascia, when stretched, produced reflex 
contractions, the same as when I saw the child nine months pre- 
vious, and that no improvement had taken place during this time, 
although under the constant influence of an elastic tractile force, 
I decided that these tissues must be divided, as I had intimated 
would have to be done nine months before. I consequently cut 
the tendo-Achillis and plantar fascia of the left foot, and dressed 
with adhesive plaster and board, as seen in Fig. 43. 

27th. — Result perfect, as far as form of foot is concerned ; 
stands flat on the floor, but the foot is inverted, the whole 
limb being rotated inward. The child lacks the power of evert- 
ing the foot or rotating the limb outward. It is easily rotated 
outward by the hand, and frequently, in stepping, the child will 
do it himself, but most of the time it remains inverted (as seen 
in Fig. 84) ; and, as he is too young to reason with, it is neces- 





FiG. 84. 



Fig. So. 



sary to contrive some plan to make the outward rotation constant ; 
and for this purpose the shoe above described was applied, which 
answers the object perfectly, the child walking quite well. {See 
Fig. 85, from photograph by O'Xeil.) 

Where there is only one foot involved in this deformity, the 
application of this rotary force to the ordinary shoe will be found 



134: 



TALIPES. 



of the greatest advantage ; but, where both feet are implicated 
in the same deformity, a similar result to the above can be pro- 
duced by a much simpler and more economical apparatus, al- 
though it is not quite so perfect in allowing free movements of 
all the parts, or so elegant in appearance. It will be found very 
useful for the poorer classes of patients. 




Fig. 86. 

It consists simply in securing the heels of a pair of common 
shoes together by an iron rod, with joints on each shoe, and the 
soles secured in the same way, with a rod a little longer than the 
one at the heel, in order to evert the feet. {See Fig. 86.) On 
either side of the shoes, iron bars, jointed at the ankles, pass up 
to near the top of the tibia, connecting in the rear with a padded 
iron belt, which buckles in front. The practical use of this ap- 
paratus is well illustrated in the following case : 




Fig. 87. 



Case. — Congenital Double Varo-Equinus (as seen in annexed 
drawing by Dr. Yale). 



CASE. 



135 



January 8, 1872, I saw the infant child of J. "W. P., of 
Brooklyn. Plaster dressings were applied. 

October 5th. — Cut left tendo-Achillis at Bellevne College. 

10th. — Heel comes down very well. There is a tense condi- 
tion of the hollow of the foot, which appears to be contracted 
integument and condensed connective tissue only ; at least the 
edge of the plantar fascia cannot be recognized. 

19th. — Cut right tendo-Achillis at Bellevne College. 

21st. — Dressed with adhesive strips alone, leaving off the foot- 
board. The wound has entirely healed. 

December 29, 1874. — Both feet were perfectly restored in 
form and position, the child stepping flat on the ground, but both 
the feet and the limbs were very strongly rotated inward (as 
seen in Fig. 88) ; and, as the parents were too poor to purchase 
the instrument with the rotating screw, I advised the father, 





Fig. 88, 



Fig. 



who was a locksmith, to construct a pair of shoes as above de- 
scribed, which, being put on the child, retained his feet in their 
normal position (as seen in Fig. 89). 

With these shoes on, the child runs about with great activity, 
his steps merely being limited in length by the bars between his 
shoes, which compel each step to be made with an eversion of the 
toes in the natural direction. In all cases of double varus, with 
this tendency to inversion and inward rotation, in the poorer 
classes of patients, this simple contrivance will be found of the 
greatest practical utility. 



136 TALIPES. 

The following case of extreme equinus — of a paralytic origin — 
is a beautiful illustration of how rapidly they sometimes recover, 
after being restored to proper position. 

Case. Paralytic Equinus, with Resulting Contracture of 
Tendo - Achillis and Plantar Fascia. — Emma H., 14 Cottage 
Place, aged twelve, was a perfectly healthy child, till she was 
upward of three years of age. She was then suddenly attacked 
with paralysis of the right upper extremity and left lower ex- 




FiG. 90. 



tremity. In the course of three or four months, the upper ex- 
tremity recovered its power. The lower extremity (left) has par- 
tially recovered. It is still shorter and smaller than its fellow. 
The measurements are : Length, right, 29 inches; left, 28 inches. 
Circumference of thigh, right, 11 inches; left, 12 inches. Cir- 
cumference of calf, right, 11 inches ; left, 9 inches. The motions 
of the thigh are perfect, and under complete control. The left 
foot presents an extreme case of talipes equiims (see Fig. 90, from 
photograph by O'Neil). The plantar fascia and tendo-Achillis 
are tense, and very tender ; point-pressure in each causes spasm. 
Owing to the distorted position of the foot, the astragalus pro- 
jects markedly, as seen in the cut. 

October 12, 1874. — Cut plantar fascia and tendo-Achillis, and 
dressed with foot-board and adhesive plaster. (See Fig. 43.) 

Pressure over the astragalus, in order to reduce it, was very 
great, and may endanger sloughing. 

Sloughing did occcur, as feared, and also on the sole, beneath 
the heel and ball of the foot. These accidents necessitated pro- 



CASE. 



137 



longed dressings. The sores finally cicatrized completely. The 
present position and condition are shown in the accompanying 
figure (91), from photograph by O'Neil, which was taken just 
three months after the operation. 

The foot is restored to almost perfect form ; and the recovery 



^ ■zZZZZ?'/'/:- 




Fig. 91. 



of muscular power to flex the foot has been more rapid than in 
any case of the same severity that I have ever seen ; and it is for 
this reason that I have thought it worthy of being recorded. 

With one more thickness of leather on the heel and sole of 
the left shoe, to equalize the length of the limbs, she walks with- 
out any limp, and has no deformity that can be discovered. 



138 CORNS.— BUNIONS. 



LECTURE XII. 

Corns. — Bunions. — Ingrowing Toe-Nails. — Supernumerary Toes. — Displacement of 
Tendons. — Bow-Legs. — Genu-Valgum, or Knock-Knee. 

Gentlemen : The amount of agony and torment suffered on 
account of corns, bunions, and ingrowing toe-nails, is all the 
apology I can offer for bringing these subjects before you. Our 
business, as surgeons, is to relieve human suffering if possible, 
no matter whether it comes from a corn or a cancer. There is 
a wide-spread opinion that the general surgeon knows nothing 
about corns, or, if he does, that he regards it beneath his dignity 
to undertake their treatment; therefore patients go to some 
chiropodist to get their corns taken care of. One of the greatest 
insults ever offered to my professional ability was given by a 
gentleman, whose family physician I had been for many years, 
when he remarked with a scowling face and snarling voice, " A 
storm is coming ; I must go to my corn-doctor and get my corns 
fixed." I asked him how he could trust his life and that of his 
family in my hands if he did not think I was capable of taking 
care of his corns % He replied that he was ashamed to ask me 
to look at his corns, as he did not think I would stoop to notice a 
corn. 

Now, gentlemen, I do not feel it beneath my dignity, and I 
hope you will never consider it beneath yours, to stoop to do 
anything that will relieve human suffering. A corn is infinitely 
more painful than a cancer, and is capable of inflicting torment 
sufficient to destroy the sweetest disposition, and upset the best- 
regulated families. This is no fancy sketch of mine ; for, without 
exaggeration, it can be practically demonstrated that entire 
families have had their peace and comfort destroyed for years, 
because one of the members had been tormented with inflamed 
corns. I have one family in my mind now (the gentleman's just 
referred to) in which domestic turmoil was the rule rather than 
the exception, and continued so for years, until the senior mem- 
ber got his corns cured. So great was the change in the dis- 
position of that man, that one of his family remarked, "¥e 
really believe that father is becoming religious," simply be- 



CORNS.— KINDS.— TREATMENT. 139 

cause peace and quiet have been restored to the household in con- 
sequence of his being relieved of the pain produced by his corns, 
and he and the family have been happy ever since. 

Now, what is the nature of these tormenting formations ? 

A cok^t is simply a localized hypertrophy of the skin, caused 
by abnormal pressure. These hypertrophied epidermal and der- 
mal layers become like dry scales or shells, with a central point 
of hardening, which is called the " core " of the corn. This lit- 
tle concretion dips down and presses upon the nerves beneath 
like a sharp-pointed instrument, and produces indescribable tor- 
ment. 

There are two varieties of corns, the hard and soft. 

The soft com is excessively tender, and is much more liable 
to become inflamed than the hard corn. This variety is more 
frequently found between the toes than elsewhere. 

The hard com has already been described. 

As before remarked, the cause of corns is abnormal pressure, 
which may be continuous or intermittent, and, in general, is pro- 
duced by bad shoeing. The shoes, instead of being made suffi- 
ciently wide at the toes and across the ball to permit perfect free- 
dom of motion at the metatarso-phalangeal articulation, so that 
the foot may expand to its full extent with every step, are made 
so narrow that undue pressure is brought upon certain points not 
intended by Nature to receive it, therefore not properly protect- 
ed, and corns are soon developed. The irritation produced by 
pressure upon these formations may give rise to reflex muscular 
contractions, which will draw the toes up, and it is not at all un- 
common to see a row of corns over the second phalangeal articu- 
lations, caused by the elevations of these joints against the shoe 
from this reflex muscular contraction. 

How are corns to be treated ? 

In the first place, you must insist upon the patient wearing 
properly-constructed shoes. Shoes must be worn which will per- 
mit expansion of the foot in all directions at every step, and then 
corns will never be produced ; but, if they have been formed, we 
must treat them. You begin by paring the corn, carefully re- 
moving the hard shell with a sharp knife as much as can be done 
without drawing blood. When that is done, rub the surface of 
the corn over with the solid stick of nitrate of silver ; this will 
remove within a few days an additional layer of hardened tissue, 



140 CORNS.— BUNIONS. 

which cannot be done with the knife without drawing blood. 
Now the corn is ready to u collar" with adhesive plaster. This is 
done most conveniently by taking narrow strips and building a 
" cob-house " around the corn, carrying it up until sufficient ele- 
vation is obtained to completely protect the corn from pressure. 

For the soft corn the application of concentrated nitric acid, 
or the solid stick of nitrate of silver, is the most serviceable treat- 
ment that can be adopted. 

First remove, by means of a knife or scissors, the thickened 
skin which covers the corn ; then wipe the parts dry and apply 
the acid or nitrate of silver. These first applications are some- 
what painful, but they are also exceedingly beneficial. After the 
application has been made, place a pledget of cotton between the 
toes so as to permit the free entrance of air. In a few days the 
dry and hardened skin caused by the caustic can be easily re- 
moved with the forceps and a second application made if neces- 
sary. This second application is not generally painful unless 
done too early, and very seldom has to be repeated. 

The reflex muscular contraction excited by a row of corns 
upon the top of the toes, along the second phalangeal articulation, 
is sometimes so great as to produce a subluxation of all the meta- 
tarsophalangeal joints. Sometimes such crooked and deformed 
toes can be harnessed into the normal position, by strapping 
them to a level surface with strips of adhesive plaster. It fre- 
quently happens, however, that this cannot be done ; if it cannot, 
then subcutaneous section of the contracted tendons will be 
necessary. 

Bunions. — A bunion is an enlargement and inflammation of 
the bursa situated upon the side of the great-toe, at the meta- 
tarso-phalangeal junction. Inflammation of this bursa is frequently 
so severe that the reflex contractions which follow produce a sub- 
luxation at this joint. In consequence of the subluxation, the 
phalanx is made to press against the nerve that supplies this por- 
tion of the great-toe to such an extent as to produce the most ex- 
quisite and torturing pain. 

This condition of affairs can be easily relieved by taking a 
strip of adhesive plaster and commencing between the great-toe 
and the one adjoining, carrying it over the end of the toe, adjust- 
ing it, and then continuing the plaster along the inner side of the 
foot, around the heel, and as far back as the base of the fifth 



TREATMENT. 



141 



metatarsal bone, where it is firmly secured with another strip of 
plaster and a roller-bandage. 

It is usually necessary, before applying the long strips of ad- 
hesive plaster, to place one or two thicknesses of the plaster just 
behind and before the bunion, to make a little elevation before 
passing over the great-toe joint. It is occasionally necessary to 
divide the tendon of the extensor proprius pollicis which has been 
long contracted, before the toe can be replaced in its normal 
position. 

In several instances under my own observation, these bunions 
have gone on to such an extent as to produce periostitis, and end- 
ing in caries of the joint. Under such circumstances, exsection was 
resorted to with complete success. In some cases the great-toe 
becomes so everted and drawn over the end of the adjoining toe 
that it cannot be brought immediately into position and retained 
by the adhesive plaster as above described. 





Fig. 92. 

In such cases it is necessary to apply a tractile force, that by 
its constant action will in time overcome the deformity, after 
which it is easily retained in position by the simple dressing be- 
fore referred to. 

To do this, a buckskin or linen glove can be made to fit the 
toe, and to this attach a few inches of elastic webbing, which 
is again attached to a piece of adhesive plaster to go around the 
foot, and is retained in place by two other pieces, as seen in Figs. 



142 INGKOWLNG TOE-NAIL. 

92 and 93, photographed from a patient of Dr. Chas. H. Lathrop, 
of Lyons, Iowa, and which give a very good idea of the deform- 
ity and the mode of treatment. 

Ingrowing Toe-Nail. — The most prolific canse of this difficulty 
is wearing narrow-soled shoes and boots. That class of people who 
will insist upon wearing narrow-soled shoes, on the supposition 
that such shoes and a high instep are elements of great beauty, 
will sooner or later become cognizant of the fact that ingrowing 
toe-nails are their legitimate offspring. Such abnormal pressure 
causes the nail to cut its way into the tissues ; the consequence 
is, the tissues surrounding it become hypertrophied, and very com- 
monly a large mass of granulations spring out from the side of 
the nail. 

The first thing to be done in the way of treatment is to guard 
these fresh granulations from the pressure of the sharp cutting 
edge of the nail, which can be done by placing a layer of cotton 
between them. The proper instrument to perform this operation 
with is a narrow thin blade without a cutting edge. (See Fig. 94.) 



Fig. 94. 

Double a few threads of cotton over the instrument, and then 
carefully carry it down between the granulations and the nail 
until the edge of the nail is reached, when the instrument is 
gradually turned flatwise and carried beneath it. 

The first application of cotton in this manner is sometimes 
exceedingly painful ; the cotton, however, should be applied in 
such a way that pressure made on the ball of the toe causes no pain 
whatever. But the toe cannot be cured until all redundancy of 
tissue is gotten rid of. 

Sometimes it becomes necessary to remove the granulations 
with the scissors ; nitric acid is an excellent application, and nitrate 
of silver is nearly as good. After the application of the cotton, 
therefore, the granulations should be brushed over with the acid 
or silver. 

As soon as the layer of dead tissue made by the caustic appli- 
cations is ready to fall off without producing haemorrhage, it may 
be removed together with the cotton fibres, and the cotton again 



TREATMENT. 143 

introduced. The second application of the cotton is not, as a rule, 
very painful. The granulations are then to be brushed over with 
the caustic, and, when the layer of dead tissue again separates, the 
dressing is to be renewed. This treatment should be continued 
until the nail has had time to grow out and protect the tissues by 
its own presence, and retain them in their proper position. The 
nail is there for the protection of the flesh, and if improperly cut, 
in addition to the abnormal pressure made by improper shoeing, 
serious trouble will be much more readily produced. The nail 
should always be cut squarely across, so as to leave the corners 
altogether free from the flesh, and permit them to act as a shield 
for its protection. 

A \ery common method of treatment is to recommend the 
patient to go to some specialist on corns and toe-nails, but you 
ought certainly to be able to treat them yourselves. 

Another plan of treatment is to cut a gutter in the centre of 
the nail, which has a tendency, it is said, to elevate the corners. 
Still another plan is to divide the nail and then strip it off. This 
operation must be repeated within a short time unless the matrix 
is also removed. 

All these plans of treatment have received the approval of the 
profession, and some of them have been extensively practised ; 
but I believe the better plan of treatment to be that which I have 
indicated ; at all events, removal of the nail should never be re- 
sorted to unless hypertrophy of the tissues about it has gone to 
such an extent as to make it impossible to repair the parts with- 
out removing the cause of irritation. If the nail is removed, it 
is necessary to remove the matrix in order to prevent the return 
of the nail. 

Supernumerary Toes and Fingers. — I call your attention to 
this class of deformities, almost solely for the purpose of impres- 
sing upon you the importance of their early correction. 

All such deformities should be attended to before the child 
arrives at an age when they will produce any mental impression. 
If permitted to remain until the child is old enough to recognize 
them, they are ever afterward a source of mortification, and, in 
some cases, produce such mental agitation as to be the cause of 
alarming nervous symptoms. 

The very fact of being conscious that the feet or hands are not 
like those of other children may be sufficient to ruin the child, 



144: DISPLACEMENT OF TENDONS. 

unless the deformity is removed, thereby relieving him of the 
self-aecusation of his deformity, and the constant observation and 
taunting of those with whom he may be associated. An example 
of the influence which such deformities may have upon the ner- 
vous system has been already given in my third lecture. These 
deformities can be much more easily corrected while the child is 
young ; growth obliterates very many of their effects, and the 
mental impression which they are liable to produce will in that 
way be avoided. (See case in Lecture III.) 

Displacement of Tendons. — There is a disability of the foot, 
caused by the displacement of tendons, which must be briefly 
referred to. 

The tendons which may be displaced are those in the groove 
behind either malleolus, in consequence of too great weight being 
thrown upon the anterior portion of the foot, thereby giving rise 
to undue strain upon the annular ligament ; rupture or stretching 
of the ligament takes place, and the tendons are dislocated for- 
ward upon the malleoli. 

Where such an accident happens, the patient can no longer 
stand, and will shut up suddenly, like a jack-knife, and as quickly 
as though he had received a blow upon the medulla. 

The accident may occur in descending stairs or steep declivi- 
ties, while wearing high-heeled shoes, which throw the weight of 
the body upon the front part of the foot, and the extra effort 
made for the purpose of retaining the body within the centre of 
gravity, produces a direct strain upon these tendons, causing rup- 
ture or stretching of the annular ligament, sufficient to allow them 
to be displaced. 

Now, if you examine the foot while the patient is sitting, the 
most careful inspection may not reveal anything abnormal ; the 
foot can be placed at right angles with the leg and the motions of 
the joint will be apparently perfect ; and, to all appearance, the 
foot and leg may be normal, the tendons in the sitting position hav- 
ing slipped back into the groove. The moment, however, these 
patients attempt to walk, or their, feet are placed in the position 
assumed in walking, the tendons will slip from behind the mal- 
leoli, and down they go. 

I cannot illustrate this peculiar accident better, than to give 
you a brief outline of a case which fell under my observation 
some years ago, and which has been fully published in the " Trans- 



CASE. 



145 



actions of the ISTew York State Medical Society," for the year 
1870. 

Miss J. S. T., of Connecticut, aged nineteen, came to my office 
upon crutches, December 8, 1869. She walked in a most 
peculiar manner ; she would balance herself upon her crutches, 
and swing both feet in front of her from eight to ten inches ; 
then bring her crutches forward, and again swing her feet for- 
ward about the same distance, and this was the extent of her 
ability to walk. The boots which she wore were stout ; tightly, 
laced around the ankles, and additionally sustained by iron bars 
bolted under the soles, and extending up on either side of the leg 
to the knee, and then securely fastened around the leg with 
strong leathern straps. The patient had discovered that she could 
not stand at all unless these iron bars were perfectly rigid, conse. 
quently no joints were allowed opposite the ankle-joints. Upon 
removing these boots and irons, it was found that motion at 
both ankle-joints was free, and the feet and legs in every way 
seemed perfectly normal. The examination was made while she 




Fig. 95. 



was sitting. When, however, T asked her to stand up, she replied 
that it was impossible, as she had not walked for four months, 
10 



146 



DISPLACEMENT OF TENDONS. 



and could not take a single step. She was lifted upon her feet, 
but she stood very awkwardly ; and the moment she undertook to 
walk she suddenly fell — with her feet flexed at an acute angle ; 
in fact, the dorsum of the foot was pressed almost against the 
tibia. 

She had fallen in this way while descending the Groton monu- 
ment in Connecticut, about four months before, and had been 
unable to take a step since that time. A closer examination of 
this girl's feet revealed the fact that whenever they were ex- 
tended upon the leg, as is necessary in stepping forward and 
backward, the tendons behind the malleoli were thrown forward 
from their grooves. (See Fig. 95.) 

This condition was believed to be due to rupture or stretching 
of the annular ligament ; the grooves below the malleoli could 
retain the tendons while the foot remained at a right angle 
with the leg ; but, as soon as extension was made as in the act of 





Fig. 96. 



Fig. 97. 



walking, the grooves were rendered more shallow, the ligament 
placed upon a stretch, and the tendons slipped at once from 



CASE. 



147 



their places, and were found upon the malleoli. When this 
had occurred, the command of the foot, of course, was imme- 
diately lost, and the peculiar " shutting up " of the limbs resulted. 
The treatment in this case was the application of a modified 
club-foot dressing. The dressing consisted of broad pieces of 
adhesive plaster, applied on either side of the leg, laying over 
them pieces of tin, having eyelets at the top, and securing them 
with a roller-bandage after the plan of Barwell's dressing for 
club-foot. 

A folded piece of plaster was passed under the foot, with eyes 
attached at each end for the purpose of attaching the hooks of 
the artificial muscles, and secured in position by means of a well- 
adjusted roller-bandage. (See Fig. 96.) By the assistance of 
this dressing, the patient was at once able to walk with comfort, 




Fig. 98. 




and experienced but little more difficulty in locomotion than any 
sound person. The dressings were changed every four or -Q.ye 
weeks, until September 20, 1870. This patient at that time had 
entirely recovered, and was able to walk without artificial sup- 



148 GENU -VALGUM OR KNOCK-KNEE. 

port. • Fig. 97 is a photographic front view of the limbs, with 
the India-rubber muscles attached. Fig. 98 is a view of the 
same after being dressed with shoes and stockings, in which 
she could walk with ease and grace, and even dance when the 
chains were hooked sufficiently tight to give her security, but the 
instant the artificial muscles w^ere unhooked she would fall 
suddenly as though she had been struck by lightning. It is 
possible for a person to walk upon a floor or level ground with 
the present style of high-heeled boots {see Fig. 99) without any 
great danger, although such persons always walk, or rather wad- 
dle, in a most ungraceful manner. But to descend a very steep 
hill or flight of stairs, with the heels thus elevated, so diminishes 
the grooves behind the malleoli, that the muscles which are put 
upon a severe strain to prevent the body from falling forward, 
cause the tendons to slip out of these shallow grooves, either by 
stretching or rupture of the annular ligaments. This is the rea- 
son why ladies wearing these high-heeled shoes are frequently 
compelled to go down-stairs backward. You can see them every 
day descending the stoops of our fashionable residences in this 
manner, making a pretense of talking to some imaginary person 
in the front-door as an excuse to hide their awkward movements. 
The shoe taken from one of our fashionable shops, represented in 
Fig. 99, is not in the least an exaggeration of what is seen every 
hour of the day in our streets, but is much higher in the heels 
than the ones that were worn at the time the injury here de- 
scribed w T as produced. 

Genu - Valgum or Knock-Knee. — This deformity consists in a 
bending of the knee inward. It is sometimes known by the term 
calf-knee. 

It results from weakening of muscular support, the joint 
being unable to properly sustain the body, and with this there is 
stretching of the internal lateral ligament. Sometimes the sup- 
port is so feeble, and the relaxation of these ligaments so great, as 
almost to permit luxation. 

The pain which is sometimes produced by walking, when the 
patient is fully grown, will excite reflex contractions in certain 
muscles, and the biceps may become so firmly contracted, that it 
is impossible to bring the limb into its normal position without 
an operation. If you see these cases before reflex contractions 
have been excited, the limbs can be easily restored to a straight 



TREATMENT. 



149 



position, but will as readily return to the abnormal position 
when the retaining force is removed. "When, however, adnlt 
life has been reached, and contracture of the biceps muscle has 
occurred, it will be necessary to divide it before the deformity 
can be corrected. It also becomes necessary in some cases to 
divide the fascia as well as the muscle before proper relief can be 
obtained. When the necessary sections of contractured tissues 
have been made, you must make extension from the foot, and 
at the same time at right angles with the side of the leg. 

This can be done by placing the patient upon a bed, the foot 
of which is elevated, and making extension upon each leg from 
below the knee by the adhesive plaster and weight-pulle} T , applied 
in the usual way. An upright is placed on either side of the bed 
opposite each knee, and a broad band, passed around the inside of 
the knee, terminates in a cord which runs over pulleys in the up- 
right, and to which is attached a weight which can be increased 
or diminished according to the patient's comfort. 

These two constant tractile forces are continued until the 
wounds made in performing tenotomy have entirely healed, by 
which time, in many cases, the legs will have become compara- 




Ftg. 100. 



tively straight. But, in the majority of instances, the patients 
will be compelled to wear an artificial support to keep them in 



150 



GENU -VALGUM OR KNOCK-KNEE. 



this position for many months, before perfect restoration will 
have taken place. 

The instrument for this purpose consists of a circular belt of 
steel around the pelvis {see Fig. 100, b), to either side of which, 
opposite the femur, a rod passes down, jointed at the hip and also 
at the knee, terminating in a circular band, which half surrounds 
the leg just above each ankle {/), or in the outer side of the shoe 
at a. These two rods are made of spring-steel, and bowed out- 
ward. Opposite the knee-joint an elastic band (c, d, 1, 2, 3, 4) 
passes around the inside of the knee, and is secured to these 
flexible rods above and below the knee ; " e " is a circular band 
around the thigh. 

The following case very well illustrates the deformity, as 
well as the practical application of the instrument : • 

Case. — Antonio, a native African, aged seventeen years, was 
brought to me from Cuba, May 14, 1864, suffering from genu- 
valgum, caused by injuries received during his passage from 




Fig. 101. 



Africa, by being too closely packed in the ship, and also by 
carrying heavy loads of sugar-cane in Cuba. 



CASE. 



151 



Present Condition (see Fig. 101). — The internal lateral liga- 
ments of the knees were very much relaxed, and the external ones 
very much contracted, which caused the considerable deformity 
of the limbs seen in the photograph. He had great difficulty in 
walking, and had become completely useless to himself or any- 
body else. 

Treatment. — I divided the tendons of the biceps muscles and 
the fascia; then straightened the limbs and kept them so for 
several days by extension and counter-extension, in the two di- 
rections (as before described), by which means they became quite 
straight. « . 

I next applied an instrument by which the knees could be sup- 
ported, while at the same time they could be flexed. (See Figs. 102 
and 103, taken from photographs.) 





Fig. 102. 



Fig. 103. 



By reference to the figures the result can be better seen than 
described. The limbs are now perfectly straight. 

Bow-Legs. — This deformity consists in a bending of the legs 
outward. 

In these cases the external lateral ligaments give way. The de- 



152 BOW-LEGS. 

formity is almost always dependent upon softening of the bones ; 
hence bow-legged children are usually those who have some con- 
stitutional disease. The deformity then is really dependent upon 
some cachexia or diathesis ; and the disease chiefly productive of 
this condition is rachitis. 

The treatment, therefore, which is necessary in such cases is 
both local and constitutional. Locally, some kind of mechanical 
apparatus will be necessary to bring the legs into the proper posi- 
tion and hold them there. Constitutionally you are to resort to 
such remedies as give support to the system, such as cod-liver oil, 
etc., but the lactate and phosphates of lime are the most impor- 
tant. The object of administering these remedies is to furnish 
some of the elements necessary to give the bone hardness and 
power of resistance to pressure. Internal treatment should not 
be commenced until the deformity has been corrected by the appli- 
cation of some mechanical apparatus. 

This may consist of a well-fitting splint of sole-leather upon 
the outer surface of the thigh, well lined and firmly secured by a 
roller-bandage. The splint should be long enough to extend 
below the knee for a considerable distance. The portion of the 
splint below the knee is left free, and projecting straight from 
the surface of the thigh. Around this portion of the splint and 
the leg place a rubber band. The constant tendency of this band 
will be to spring the bones into a straight position.* 

The bending must be done gradually, but, if the elastic ten- 
sion is steadily applied, the outward curvature of the bones of 
the leg can be overcome and the leg made straight. 

Such a plan of management you will find much easier and 
better than any attempt to adapt an instrument to the distorted 
limb. In order to make this splint more stiff, it is well to secure, 
on the outer side of the leather which surrounds the thigh, an 
iron rod or piece of wood extending down as long as the limb ; 
the leather which nearly surrounds the thigh will keep this rod 
or wooden splint in position, and the iron rod or strip of wood 
will prevent the leather from bending. 

If, however, it is desirable to have the benefit of some nicely- 
arranged instrument, the one illustrated in the annexed diagram 
may be employed. 

It consists of two upright lateral bars fastened to the band, 
which encircles the thigh above b, and terminates in a shoe below. 



BOW-LEG APPARATUS. 



153 



At c is a joint opposite the ankle-joint, and a pad which presses 
against the foot. At d is a pad which presses against the thigh 




Fig. 104. 



and at a and e are bands which pass around one of the upright 
bars, and the leg where the limb is most curved, for the purpose 
of bringing the leg in a straight position. 



LECTURE XIII. 



DISEASES OF THE JOINTS. ANKLE-JOINT. 

Anatomy of the Ankle-Joint. — Pathology of Disease of. — Symptoms. — Treatment. 

Gentlemen : We will next study diseases affecting the ankle- 
joint. This subject is a proper one for consideration by the or- 
thopedic surgeon, for the diseases of this joint frequently termi- 
nate in deformity, and, as " an ounce of prevention is worth a 
pound of cure," the method of preventing deformity during the 
continuance of the disease makes it a proper subject for consid- 
eration in our department. It is to the pathology, symptoms, and 
treatment of the disease, then, that I shall specially direct your 
attention. Before proceeding, however, to the study of the dis- 



154 DISEASES OF THE ANKLE-JOINT. 

eases affecting the ankle-joint, we must turn our attention to the 
construction of this joint, and to some of its anatomical peculiari- 
ties. 

Anatomy. — The bones which enter into the formation of the 
ankle-joint are the lower extremity of the tibia with its malleo- 
lus, the lower extremity of the fibula, or the external malleolus, 
and the upper convex surface of the astragalus. These articular 
surfaces, covered with cartilage, are held in place by the internal 
and external ligaments and the anterior ligament of the ankle- 
joint, which are lined by synovial membrane. 

The important thing to be remembered with reference to this 
joint is, that it is simply a hinge-joint, has a to-and-fro move- 
ment and no other. The articulation between the astragalus, the 
lower extremity of the tibia, and the two malleoli, is so complete, 
close, and perfect, that it will admit of no lateral movement 
whatever. This is one of the statements which I make with 
positiveness. The apparent lateral motion which takes place is 
not at the astragalo-tibial articulation, but below, at the articula- 
tion of the astragalus with the os calcis. When the toes are 
turned out or in, it is in obedience to rotation of the leg and thigh 
at the hip-joint ; or, if the leg is flexed upon the thigh by the 
action of the biceps and tensor vaginse femoris, giving a revolv- 
ing motion to the head of the fibula. 

Pathology. — All lateral movements made at the ankle-joint 
are done at the expense of an injury to the structures of that 
joint ; for no lateral movement, external or internal, abduction 
or adduction, can take place without producing undue pressure 
against the synovial membrane and articular cartilages, or the 
basement membrane beneath them. These articular cartilages, 
like those in other joints, are elastic, non-vascular, and receive 
their nutriment by imbibition from the synovial membrane and 
from the vessels of the articular lamella. Necrosis of these car- 
tilages takes place with the greatest rapidity on account of the 
low degree of vitality they possess, hence they are the source of 
great danger when, in any manner, the tissues beneath them be- 
come so disturbed as to interfere in the least with their nutrition. 
I do not believe, however, that disease ever commences in the car- 
tilage itself. The malleoli, which stand as guards on the side of 
the joint, are not so well protected, because in the normal move- 
ments of the foot thev are not subject to much pressure, and con- 



PATHOLOGY. 



155 



sequently the • cartilage covering them is not so thick as that 
covering the top of the astragalus or bottom of the tibia. You 
have probably all at some time twisted your ankle in walking, 
and you cannot have failed to notice how instantly the mal-posi- 
tion of the joint is followed by a spasm of the muscles of the leg. 

We may have diseases of the ankle-joint which commence 
either in the ligaments or in the synovial membrane ; or, which 
I believe to be far the most frequent, in the articular lamella im- 
mediately beneath the articular cartilage. 

In a great majority of instances what we have to deal with is 
an extravasation of blood beneath the synovial membrane, or 
between the cartilage and bone, quite analogous to the " blood- 
blister " which is formed upon the external surface whenever the 
skin is severly pinched but not broken. This may occur either 
upon the astragalus, or at the lower extremity of the tibia, or, still 
more commonly, as the result of pressure produced by the astrag- 
alus against the inner surfaces of the malleoli, which are not suffi- 
ciently protected to resist severe pressure. Under such circum- 
stances, no swelling occurs that can be seen ; there is pain, proba- 
bly, but the cases are very liable to be neglected, their importance 
overlooked, and thus a slight injury, producing only trifling dam- 
age at first, may be permitted to go on and develop the most 
serious condition, ending in inflammation, which goes on to soften- 
ing of the bone, necrosis of the cartilages, and destruction of all 
the tissues involved in the joint. The inflammation may extend 
to other bones, and you may have as a result softening and caries 
of all the bones of the tarsus, as in the case you now see before you. 




Fig. 105. 



{See Fig. 105.) These are the cases that are called " scrofulous 
disease of the ankle-joint." There is no scrofula about it in the 



156 DISEASES OF THE ANKLE-JOINT. 

vast majority of cases. It is simply inflammatory softening, 
ending in caries and necrosis of the bones, and ulcerative destruc- 
tion of other tissues entering into the formation of the joint; 
and instead of being constitutional in its origin, dependent upon 
a constitutional cachexia, it is simply inflammation of the joint 
dependent upon injury, consequently traumatic in its origin. 

When children who have a scrofulous diathesis receive, as of 
course they may, an injury sufficient to lead to serious results, such 
results are usually more rapidly developed and less amenable to 
treatment than when the injury occurs to previously healthy 
children, or children born of healthy parents. 

Symptoms. — With this view of the subject, gentlemen, you can 
at once see the very great importance of early recognition of the 
exact nature of these trifling injuries to the structures of the joint, 
which may lead, if neglected, to such serious results. To this end, 
therefore, I shall endeavor to point out to you in the plainest 
manner possible the symptoms by which you will be able to recog- 
nize them in their very earliest stages, so that you may be able to 
adopt a plan of treatment which will prevent such unfavorable 
results. 

First, then, if the twist, wrench, sprain, or bruise, which the 
patient has received has produced an injury that involves the 
synovial membrane chiefly, it will be followed very speedily by 
increased effusion within the joint, giving to the joint a peculiar 
fullness in front of either malleolus, within which swelling an indis- 
tinct fluctuation can be recognized. This in a few hours is followed 
by great heat and intense pain ; a sense of tension, accompanied 
by throbbing, and great tenderness and pain will be present when 
the articulating surfaces are crowded together and slightly twisted 
upon each other. If, on the other hand, the ligaments are involved 
more than the synovial membrane, the injury will not be attended 
with so much swelling as when the synovial membrane alone is 
involved ; and the tenderness and pain are not produced by press- 
ing the articular surfaces together, but, on the contrary, are relieved, 
and it is by making extension and rotation, together with pressure 
upon the ligaments over their points of attachment, that pain is 
produced and tenderness detected. If, however, the injury is the 
result of a blow or concussion, with or without much twisting, but 
received in such a manner as to produce rupture of blood-ves- 
sels underneath the articular cartilage, in the articular lamella, 



PATHOLOGY. 157 

either at the top of the astragalus, base of the tibia, or inner sur- 
faces of the malleoli, then there will be but slight pain at first, 
but afterward the suffering will be altogether out of proportion 
to the appearances presented. At first the extravasation of blood 
into the bone is very slight, and, being in a tissue which cannot 
swell, no apparent enlargement takes place ; nor is discoloration 
observed, because the extravasation is so deep-seated. The liga- 
ments not being specially involved, making them tense does not 
produce pain. All these facts add to the deception, and make us 
very liable to pass over the case as one of trifling importance. 

When this accident has occurred, the only manner in which it 
can be recognized is by means of direct pressure upon the part 
affected by the extravasation. The seat of the injury may be at 
any point on the surfaces of the joint, and it therefore becomes 
necessary to make pressure upon all parts of the joint, by moving 
the bones in every direction, and also making lateral pressure so 
as to bring it to bear upon the sides of the malleoli. 

"We are not safe in giving a diagnosis in these cases until in 
this manner we have thoroughly explored every portion of the 
joint. 

You must not, however, entertain the idea that you will see 
very many cases in which the symptoms of either one of these 
three conditions just described will be present, clearly defined 
and alone, unassociated with symptoms indicating the presence of 
one and perhaps both of the other conditions. A wrench, or 
sprain, or bruise, may be received, which will give rise to symp- 
toms indicating injury to all the structures of the joint — ligaments, 
synovial membrane, and articular lamella; but your examination 
must be conducted upon the same plan in such cases, for in that 
manner only will you be able to determine positively what struct- 
ures have become involved. 

The important thing for you to recollect and always keep in 
mind when you are called to examine and treat this class of cases 
is, that serious injuries of joints compel attention, and slight ones 
are neglected, and, generally speaking, the slighter the accident 
the more apt to be neglected ; but those are the very ones which 
are exceedingly dangerous. 

If an injury be severe — for example, a fracture involving a 
joint, a dislocation, or even a severe sprain — it cannot be overlooked 
or neglected ; surgical aid is indispensable, and is immediately 



158 DISEASES OF THE ANKLE-JOINT. 

called for, and generally a cure results after a reasonable time. 
"When, however, a person receives what is termed a " slight sprain 
of the ankle," the amount of mischief from a neglect in recognizing 
what structures are involved, and instituting a proper method of 
treatment, is often extreme, and may terminate in a sacrifice of 
the limb as the only remedy for a chronic inflammation of the 
joint involved. 

Let us, then, next consider how such disastrous results may 
be brought about. We will take, for example, a simple sprain of 
the ankle, which is very common, and from which all of you, it 
may be, have suffered. As I have already told you, a " blood- 
blister," or extravasation, is first produced. Such a "blood- 
blister" is considered as insignificant under ordinary circum- 
stances, if it be allowed immediately to heal. If, however, the 
"blood-blister" is constantly irritated by friction, an ulcer is 
formed which rapidly increases in size, and involves the deeper 
tissues. 

This, I believe, is exactly the morbid process going on in one 
of these neglected sprained ankles. The small quantity of blood 
effused behind the synovial membrane, or between the cartilage 
and bone, would be speedily absorbed, if sufficient rest were 
allowed to the part ; but there is no swelling, and little pain, it 
may be, to give warning of the mischief done, and the patient 
does not stop his usual walks and exercise. .The "blood-blister" 
becomes irritated and increases in size, and finally, on account of 
the disturbance produced, he is obliged to lay by for a short time. 
The trouble apparently disappears, and he resumes his avocations ; 
a slight over- exertion, however, brings back the same train of 
symptoms, namely, exhaustion, stiffness, pain, tenderness, and 
perhaps swelling. This is repeated again and again, as often as 
rest allays and exertion awakes the morbid process, the attacks 
becoming more and more severe and prolonged, till at last the 
condition of chronic inflammation is reached. The liquid now 
contained in the joint is abnormally abundant, and is changed 
in consistency ; instead of the clear synovia, there is an opaque, 
viscid substance. To this, in part at least, is due that peculiar 
distention and "boggy" feel which the joint now presents. 
Ordinarily, suppuration very rapidly supervenes upon this con- 
dition of the articulation. The cartilages become necrotic, and 
caries of the adjacent surfaces of the bones is set up. The pain 



PATHOLOGY. 159 

now is often excruciating, as is generally the case when cartilage 
is undergoing disintegration. As a result of this process, the 
constitutional disturbance is usually quite severe, and the pain 
produces sleeplessness and loss of appetite. The muscles affect- 
ing the articulation are constantly " on guard " to fix the joint, 
and prevent any rubbing together of its surfaces. 

Such constant tension causes an atrophy of the limb both above 
and below the joint ; though in the latter situation it may be 
obscured by the swelling. At night, when the sleep has become 
so sound that the muscles relax their tonic contraction, mo- 
tion will take place in the joint, and the patient awakes with a 
sudden, piercing shriek. So quickly do the muscles resume their 
conservative contraction, that, by the time the nurse has reached 
the bedside, the patient is again asleep or is unconscious of the 
cause of his awakening. This pressure of the join t-surf aces, 
although painful, is less so than the motion which would occur if 
the muscles were not thus contracted, but it very much increases 
the destruction of the cartilage and bone, and you will find, in 
post - mortem examination of the parts, erosion of the tissues 
farthest advaaced at those points where the • pressure from mus- 
cular contraction has been greatest. 

When the joint is thus filled with a liquid, which is causing 
disturbance as a foreign body, one of two terminations is neces- 
sary, the absorption or evacuation of the liquid. 

If there is a probability that absorption of the fluid can take 
place, it is best promoted by fixing the joint in such a manner as 
will relieve the pain and defend it from attrition of the articular 
surfaces, thus allowing our attempts to renovate and invigorate 
the system really to take effect. 

If in addition we apply some apparatus, which will permit 
the patient to take out-of-door exercise without disturbing the 
rest so essential to the articulation, we shall have done the 
best thing possible, and, fortunately, our efforts will often be 
crowned with success. If, however, such precautions are not em- 
ployed, and often, indeed, in spite of them, the disease proceeds 
to ulceration of the bone, and, now if we do not make an exit for 
the pus, it will eventually make one for itself. In the mean time, 
however, long and tortuous sinuses will have formed, the pus 
burrowing this way and that among the muscles and between 
fasciae, so that these tissues are involved, while by long-continued 



160 DISEASES OF THE ANKLE-JOINT. 

action of the pus the disease of the bones becomes greatly ex- 
tended. Much of this trouble is avoided by opening the joint 
when we are convinced that any considerable amount of pus is 
contained within its cavity. The old-established doctrine of the 
great danger of opening a joint still continues, for the most part, 
to be fully accepted to-day. I must, however, express my dissent 
from this general belief. Of course, no one would dream of 
opening a joint so long as there was a probability of the integrity 
of the articulation; but when the articular surfaces are wholly 
or in part destroyed, then, I say, the characteristics of a joint are 
also destroyed ; there remains nothing but an abscess of a joint, 
which is to be treated in the same manner as an abscess else- 
where, or, more exactly, as an abscess connected with bone. 

When the disease has advanced to this stage, the case is looked 
upon by the mass of the profession as an unmistakable illustration 
of " scrofulous disease of the joint," but I believe it to be the result 
of inflammatory processes dependent upon a traumatic cause. 

Treatment. — We are now ready to study the treatment to be 
adopted for the various conditions which have been described. 
In all sprains or bruises affecting the ankle-joint, involving the 
ligaments or producing effusion of blood, the very best treatment 
that can be adopted is to immediately immerse the limb in water 
of as high temperature as can possibly be borne, gradually in- 
creasing this temperature, until the heat is carried up to the 
highest point the patient can tolerate, and then maintain this for 
a varying length of time, perhaps several hours, until all pain 
upon pressure and slight movement has entirely subsided. 

Many have recommended that various articles be added to 
the w T ater, such as wormwood, smartweed, wood-ashes, Pond's 
extract, tincture of arnica, etc., etc., but it is questionable if any 
of them are of much service ; the principal agent is the heat, and 
that can always be obtained, whereas the articles recommended 
may not be at hand, or cannot be procured. When the pain is 
relieved by the foot-bath, the patient should be placed in an hori- 
zontal position, with the limb elevated and firmly bandaged with 
a flannel roller from the toes to the knee, and then kept wet, or 
dry, as may be more agreeable to the feelings of the patient. 

Perfect rest of the limb 'in the elevated position, with this 
even compression, is to be maintained until all tenderness upon 
firm pressure has completely subsided, and until the limb can be 



ELASTIC COMPRESSION. 161 

held in the dependent position without producing any unpleasant 
symptoms. If the synovial membrane has been involved in the 
injury, and effusion and over-extension of the joint have ensued, 
elastic compression is the essential element in the treatment. 
This can be obtained by surrounding the joint with a large 
sponge. The sponge should first be thoroughly saturated with 
warm water, then made as dry as possible by squeezing with the 
hand, and finally made to completely surround the joint, being 
particular to have it quite thick over the instep and both malleoli. 
After it has been properly applied around the joint, bind it firmly 
in place with a bandage that will permit water to pass through its 
meshes. This bandage should include the foot, ankle, and leg, and, 
after the sponge has thus been compressed by the bandage, both 
sponge and bandage should be thoroughly soaked with water ; the 
sponge, absorbing the water, will increase in size, and, as the band- 
age prevents it from expanding outward, the pressure induced by 
its enlargement is done at the expense of additional pressure of 
the parts enveloped by the sponge. This method of making 
elastic pressure is within the reach of every surgeon. 

A more convenient method of making even pressure over the 




Fig. 106. 



joint is by means of the double India-rubber bag, manufactured by 
Tiemann & Co. of this city. It is simply an India-rubber sac with 
double walls, which incloses the ankle and foot; a tube connects 
with this hollow bag, which can have warm water poured into it, 
and then the bag is to be blown up either by the mouth or a pair 
of bellows, and a stopcock turned which retains the air. (See Fig. 
11 



162 DISEASES OF THE ANKLE-JOINT. 

106.) In this manner pressure can be made which will be exceed- 
ingly powerful, and yet so soft and elastic as to be easily borne. 
Such pressure, constantly applied, on account of its elastic charac- 
ter, will cause an absorption of the fluids within the joint ; and 
also, by this very pressure, we have a tendency to separate the 
articulating surfaces ; therefore, to a very considerable extent, we 
secure the double advantage of pressure and extension and coun- 
ter-extension, by forcing the fluid into the joint, thus preventing 
the articulating surfaces from being forced upon each other by 
muscular contraction. After a few days have elapsed, friction 
with the hand is of the greatest possible advantage ; but to afford 
the best result it should be much more briskly applied, and con- 
tinued for a much longer time, than has generally been done by 
the great majority of surgeons. 

In fact, many cases of quite severe injury affecting the ankle- 
joint, or any other joint, such as a wrench or a sprain, will yield, 
in a comparatively short time, to manipulations and friction per- 
sistently applied for some few hours every day. 

You may call this " massage " if you have a fancy for a new 
name, but I have employed this plan of treatment for many years, 
and long before the term "massage" was applied to it. It is, 
however, sometimes necessary that a method of treatment should 
go across the water and be baptized with a new name before it 
becomes popular. 

So much, gentlemen, for the treatment to be adopted when 
the injury is first received. This is the important time for the 
application of measures which are to prevent the further develop- 
ment of the disease, and, could such treatment be faithfully car- 
ried out in every case from its earliest commencement, there 
would rarely be need of the mechanical appliances and surgical 
interference to be described at our next lecture. 



INSTRUMENT. 163 

LECTURE XIY. 

DISEASES OF THE JOINTS. — -AXEXE- JOINT (CONTENTED). 

Treatment (continued). — Description of Instrument. — Mode of Application. — Cases. — 
Disease of the Tarso-Metatarsal Articulation. — Case. 

Gentlemen : At the close of my last lecture I was speaking 
of the importance of early treatment of injuries of the ankle- 
joint, hoping thereby to prevent destructive disease. Unfortu- 
nately, however, very many cases pass unrecognized, or, being 
recognized, are neglected, and gradually arrive at a stage in which 
surgical aid is sought, and then they probably are in a condition 
which will demand some more formidable method of treatment 
than that which has already been given ; and it is to this part of 
our subject that I invite your attention to-day. \YTien there is 
still hope of preserving the joint intact, which is to be deter- 
mined by the length of time the condition has existed, the 
amount and character of the fluid in the joint, the degree of 
constitutional disturbance, and the general condition of the joint, 
I employ an instrument which I have devised for this purpose. 

This instrument consists of a firm steel plate, made to fit the 
sole of the foot ; at the heel is a hinge-joint, and attached to it a rod, 




Fig. 10T. 



slightly curved at the bottom, and extending up the back of the 
leg to near the knee. Over the instep is an arch, like the top of 
a stirrup, with a hinge- joint at its summit from which springs an- 
other rod, which runs in front of the leg, of equal length with the 



164 



DISEASES OF THE ANKLE-JOINT. 



one behind. These rods are made with a male and female screw, 
or ratchet and cog, for extension, and connected at the top by a firm 
band of sheet-iron, on one side of which is a hinge, and a lock 
on the other, like a dog-collar. (See Fig. 107.) In front of the 
arch that goes over the instep is a joint in the foot-plate which 
permits flexion of the toes. 

The instrument is applied with firm adhesive plaster, cut in 
strips about one inch in width, and long enough to reach from 





Fig. 108. 



Fig. 109. 



the ankle to near the tubercle of the tibia, and placed all around 
the limb, as seen in Fig. 108. 

The plaster is secured in its position to within a few inches of 
its upper extremity by a well-adjusted roller, as seen in Fig. 109. 

The instrument is fixed, and the foot firmly secured, by a 
number of strips of adhesive plaster, as seen in Fig. 110. 





Fig. 110. 



Fig. 111. 



A roller should be carefully applied over this plaster to pre- 
vent its slipping, and the ends of the plaster at the top of the 



CASE. 165 

instrument turned over the collar, which has been previously 
locked, just tight enough to be comfortable, and secured by a turn 
or two of the bandage, as seen in Fig. 111. 1 

With the instrument accurately adjusted, the extension can 
be regulated by the key, so as to make the patient comfortable. 

If, however, the symptoms show the system to be suffering 
from the poison of the pus retained in the joint, or if, the joint 
being open, the patient is sinking under the drain of prolonged 
suppuration, the diseased bone should at once be removed, and a 
perfect drainage established, so that no pockets or sinuses can be 
formed. If this latter accident be allowed to occur, the disease 
of the bone will not be arrested, and the operation will therefore 
be useless. 

Now, you cannot in the ankle exsect the bone, as you can at 
the shoulder or hip, by a straight incision. In these orbicular 
joints the operation is simple ; you have but to cut down to the 
bone, open the capsule, throw out the head of the bone through 
the " button-hole " slit, remove it with the chain-saw, and finish 
with the rongeur or forceps, if necessary. 

But in the hinge-joints, as a rule, and especially such com- 
plicated ones as the ankle, you cannot safely operate in this way. 
To make the necessary incisions, the muscles and vessels must be 
divided transversely, and so much damage is thus done as to seri- 
ously interfere with the success of the operation. The elbow- 
joint is the exception to this rule, the ordinary operation for 
orbicular joints, i. e., a single incision parallel with the muscular 
fibres and vessels, being applicable to it. In view of this, I have 
for many years refused to operate by exsection upon the ankle 
and wrist joints. The method which I substitute I shall now 
proceed to demonstrate to you, as by so doing I can much more 
clearly explain and more firmly impress the essentials of the op- 
eration than by any amount of lengthy description. The history 
of the case before you is, in brief, as follows : 

. Lewis R, aged nine ; last winter, in December or January, 
sprained his ankle while skating. For some time he experienced 
no trouble in the joint, but eventually it began to swell, and the 
disease ran the usual course, till he was admitted to Bellevue 
Hospital in July with an open joint. On the 22d of that month 
I removed what dead bone could be found, and passed a seton of 

1 The figures represent the instrument as applied to a joint which has been setoned. 



166 DISEASES OF THE ANKLE-JOINT. 

oakum through the joint from side to side below the malleoli. 
The joint was fixed by a plaster-of -Paris splint, which was 
changed in a few days for one of leather. The case remained 
under my care but a short time. The surgeon to whose care he 
next passed, holding different views regarding the treatment of 
these cases, removed the seton a month after it had been inserted, 
and after that the treatment was simply applying poultices and 
stimulating dressings. The surgeon now having charge of the 
case has kindly consented to surrender it to me for one year, at 
the end of which time it is to be returned to him for an ampu- 
tation. You see, he has no faith in my plan of treatment. 

You will notice the foot and ankle present the usual appear- 
ance found in chronic inflammation and suppuration of this artic- 
ulation complicated with caries of the tarsal bones. (See Fig. 
105.) 

The usual contours of the joint are obliterated, and it presents 
an irregularly rounded tumefaction, nearly twice the size of the 
opposite ankle, of a purplish color from venous congestion, which 
has been aggravated by long-continued poulticing of the part, and 
a boggy, doughy feel, with several open sinuses, through which 
the probe readily passes to dead bone. I would remark, in this 
connection, that the long-continued use of hot poultices to a joint 
in the condition of this one is always injurious. The heat soli- 
cits more blood to the part, and the relaxing effect of the fomen- 
tation favors the passive congestion of the capillary vessels, and 
thus adds to the (Edematous and " boggy " condition of the part. 

While the patient is under the chloroform, 1 shall remove the 
carious bone sub-periosteally. If I destroyed the periosteum, I 
should defeat the chief object of my operation, namely, the 
regeneration of bone and the formation of a movable joint. 

Into the sinuses already existing I pass this instrument (Fig. 



j.beynders &co. 
Fig. 112. 

112), which I have formerly called an " oyster-knife," as its form 
most resembles that of the implement used to open oysters, but 
it is more properly called a periosteal knife, or elevator. 



CASE. 137 

The blades are strong and wedge-shaped, the edges not being 
sufficiently sharp to cnt the soft parts. With it I can enucleate 
the diseased bone without fear of lacerating the vessels, perios- 
teum, or other important parts. Make your excavation thor- 
oughly, seeking to remove not only all the dead bone, but espe- 
cially the gelatinous matter so abundant in these diseased joints. 
In this case you see I have removed, besides a mass of detritus, a 
piece of carious bone about the size of a hickory-nut, which is 
from the lower end of the tibia, including a part of the articular 
surface. If I can, I generally, before finishing the operation, 
place my finger within the joint, to more perfectly assure myself 
that I have reached all the diseased structures. 

Now, I draw completely through the joint, and also through 
the other sinuses, a large seton of oakum, saturated with Peru- 
vian balsam, letting the ends extend beyond the ulcers for several 
inches. The advantage of the oakum I will mention in a 
moment. 

The operation proper is now complete. We now place the 
foot in a comfortable position, and at a proper angle with the axis 
of the limb, and fix it there by an anterior splint of plaster of 
Paris, from which arms extend around the foot and leg below 
and above the wound, so as to leave the latter entirely free for 
daily dressing. (See Fig. 116, with plaster -of -Paris splint.) 

When the plaster has " set," envelop the joint with a thick 
pad of oakum, filling with it the fenestrge in the plaster dressing, 
and bandage the foot and ankle as firmly as possible. 

The reason why I insist upon the use of oakum is this : it is 
elastic and makes an equable pressure, but at the same time it is 
always pervious to the escape of pus. You know how dense 
compressed cotton is, how it cannot be wetted thoroughly for a 
long time ; lint has much the same qualities. I sincerely believe 
that the life of many a soldier was lost during the late war, sim- 
ply from the lint with which his wounds were dressed, or rather 
plugged. Beyond this advantage, oakum is particularly service- 
able as a seton by reason of its strength, and the tar with which 
it is so thoroughly impregnated prevents its becoming readily 
foul. Therefore, gentlemen, I use lint only to arrest or prevent 
haemorrhage, and never after suppuration is fully established. 

In this case, then, I have accomplished what ? By my ex- 
cavation I have removed the essential morbid cause; by the 



168 DISEASES OF THE ANKLE-JOINT. 

splint I prevent, motion, which would be a cause of a relapse ; 
and by the firm pressure I have given the enfeebled and stagnant 
circulation of the parts the best possible support. The seton will 
be moved daily, and the soiled part cut off ; you can easily twist 
on more oakum, and thus continue it as long as necessary, and 
what debris of carious bone has been left behind will be drawn 
out entangled in the fibres of the oakum. By-and-by, when the 
reparative process shall have been fully established, the extension 
instrument, which I have already described to you, will be applied, 
and the boy allowed to go about. Even before that, if your 
patient is of sufficient age to take proper precaution against 
injury, he may be allowed to go about a little on crutches. In 
this event, however, you will be especially careful that the band- 
ages be applied with sufficient accuracy and firmness to counter- 
act the congestion from gravitation of blood to the part. 

I hope, gentlemen, before this winter session closes, to be 
able to present you the result of the case I have just operated 
upon, but a longer time may be necessary for a perfect cure. 1 
I have, however, here several persons upon whom I have already 
operated, and who, living in the city, have consented to come 
before you in order that you may see what degree of success you 
may anticipate. And first, let me present one which should fol- 
low the case just operated upon, because they both exemplify the 
danger of the too speedy removal of the setons. This one, more- 
over, will satisfy any doubt which may have arisen in your minds, 
regarding the propriety of repeating the gouging and setoning 
process, if necessary. 

Case. — John E., Davenport, Iowa, aged twenty-seven ; la- 
borer. In November, 1866, while ploughing, he sprained his 
left ankle. He did not, however, experience sufficient incon- 
venience from the injury to prevent him from working until four 
months had elapsed, although during this interval he was aware 
that the joint was not quite sound. From the time he was 
obliged to give up work, until he came to New York, in April, 
1868, he had been under surgical treatment. His attendant 
advised him, last spring, to come to New York to consult me. 

The foot presented the general appearances already described 

1 This child was presented to the class February 25, 18*75. The wounds all healed 
but one, and from it there was very slight discharge. Motion of joint good, and the 
child's general health perfectly restored. 



CASE. 169 

in relating the other cases. Below both malleoli were openings, 
and through each dead bone could be recognized by the probe. 
Still another fistula opened on the outer side of the tibia, about 
five inches above the articulation. The general health of the 
patient was considerably impaired, and he was quite thin. 

At that time, April, 1868, 1 dug out a large quantity of cari- 
ous bone, consisting of the scaphoid bone, a part of the astragalus, 
and pieces which appeared to be parts of the smaller tarsal bones. 
The calcaneum was then quite sound. The dressing, with the 
seton and plaster-splint, was applied as you have already seen 
done. Three weeks after the operation, I sent him to Bellevue 
Hospital, as his lodgings were not suited to his wants. The sur- 
geon to whose care he fell, removed the plaster-splint at once, 
and four weeks later removed the setons. This change of treat- 
ment was due to the fact that the surgeon holds the opinion that 
motion is necessary to the cure of the joint, in order to excite a 
healthy action. Now, I have already insisted upon the absolute 
necessity of rest in certain stages of the diseased joint, but there 
is a period when motion becomes necessary, and I should do well, 
I think, to explain to you when motion is injurious, and when it 
is demanded. 

So long as there is active inflammation in a joint, motion is 
injurious, and rest absolutely necessary. In the first stages of 
inflammation of any joint, rest is also imperative, and, in fact, 
is the essential element of the treatment ; and, as long as acute 
pain is produced by pressing the synovial surfaces and articu- 
lar cartilages together, rest must be enjoined; or, if motion of 
the joint is requisite, in order to prevent anchylosis, then this 
motion must be always accompanied with extension, in order to 
relieve this pressure. But, when pressure can be borne without 
pain, and the difficulty in motion depends upon the contraction 
of tissues around the joint from want of use or from deposits, as 
the result of an antecedent inflammation, then motion — passive 
motion — applied with discretion, is just as much a part of the 
treatment as rest was in the earlier stage of the disease. 

So, too, when a joint has been opened for suppuration and 
caries, as long as there is dead bone remaining and excessive 
suppuration, rest is imperative and motion injurious ; but when the 
dead bone has all been exfoliated and removed, the pus diminished 
and of a healthy character, then the setons can be discarded, the 



170 



DISEASES OF THE ANKLE-JOINT. 



sinuses allowed to close up, and passive motions commenced, 
which can be increased with judgment and discretion, in order to 
make a new or artificial joint in the new bone formed from the 
original periosteum, which, as I stated to you before, must 
always be left for this purpose when making your resections. 
When I came on duty, the following July, I found the pa- 




Fi«. 113. 

tient's foot presenting nearly the same appearance as at first. The 
premature removal of the setons had allowed the accumulation 
of pus within the joint, and the caries had been reestablished. 
Examination with the probe showed the calcaneum to be now in- 
volved. The operation of excavation was repeated, and a large 




Fig. 114. 



portion of the os calcis removed, a seton passed through the joint, 
another from each of the openings on the side to an artificial 
opening at the point of the heel, so that, in any position the pa- 
tient might assume, the drainage would be perfect. By refer- 
ence to Figs. 113 and 114, you see the condition of the patient at 
the time the photographs were taken. The setons had all been 



CASE. 171 

removed, and the wounds had closed. There was no pain in the 
joint. The patient walked without limping, showing that there 
was no tenderness. The fistula on the leg and that on the point 
of the heel were so perfectly healed that the cicatrices could be 
found only with difficulty. The contour of the foot was so perfect 
that one would naturally doubt that so much bone had been re- 
moved. This was, I think, evidence that the bones of the tarsus 
had in some sort been reproduced by the periosteum. I have 
never had the opportunity of examining, post mortem, any of 
these reproduced ankle-joints. 

This man at that time appeared to be perfectly cured (see 
Figs. 113 and 114), and you might think that treatment should 
be suspended. On the contrary, after this point has been 
reached, the limb must be carefully bandaged for months to come, 
until all the discoloration from congestion shall have disappeared. 
If you neglect this precaution, there is great danger of a relapse. 
You will notice in these cases, when you let the foot hang down, 
that the skin becomes discolored from capillary congestion, and 
the roller should be reapplied with considerable firmness, in order 
to support the circulation in these new tissues, and this accurately- 
adjusted compression must be continued for months after the 
cure has been apparently complete. 

Case. — Annie L., aged four, came to my clinic January 13, 
1875, with the following history : 

She was injured, as the father states, by jumping down two 
steps, on December 26, 1873. She went to the German Dispen- 
sary from January 4 to March 11, 1874, when she went to the 
Forty-second Street Hospital. Continued under treatment there 
until four days since. The only symptom for which she was 
sent to the German Dispensary was the inability to walk. 

She is now much emaciated and suffering intense pain ; the 
mother says she screams out at night every time she gets asleep, 
and cannot be moved without hurting her — cannot have the 
slightest motion at the ankle-joint without extension. Appetite 
bad ; position as seen in Fig. 115 ; ankle much swollen, with open- 
ings on inner and outer side. 

Before the class at Bellevue College, I dilated the sinuses, and 
gouged out a large quantity of dead bone ; passed an oakum 
seton from side to side through the ankle-joint (Fig. 116, 1, 1), 
and another from front to heel (Fig. 116, 2, 2), and, putting the 



172 



DISEASES OF THE ANKLE-JOINT. 



foot into its natural position, secured it there with plaster-of -Paris 
bandage, leaving fenestrse as seen in Fig. 116. 

Jcmuary 20, 1875. — Child was at clinic, much improved. 
Her appetite has returned, she is free from pain, and she sleeps 
well ; the wound presents a healthy aspect. Can bear weight of 





Fig. 115. 



2 1/2 



Fig. 116. 



body on foot when plaster dressing is applied. Only complains 
when oakum setons are drawn through. One or two small pieces 
of bone have come out on the oakum. 

27th. — Yery much improved ; runs around without pain ; 
ankle simply stiff from the plaster. Discharge much diminished 
and more healthy. 

February 3d. — At clinic, rosy-cheeked and playful ; discharge 
very slight. Mother has dressed the ankle daily. 

March 31st. — Was at the clinic, looking the picture of health. 
Seton through heel had been out some days; no discharge from 
antero-posterior opening, and very little from lateral sinuses. 
Child runs on plaster splint without any pain. Removed plaster 
casing, and she could bear her entire weight upon her foot. As 
there was still a slight discharge, left seton in as seen in Fig. 117, 
from sketch taken March 21, 1875. 

August 1, 1875. — Recovery perfect, with motion (see Fig. 
118). 

Case. Supjmration and Caries of both AnMe-Joints from 
Injury ; Double Talipes Equinus / Operation; Recovery, with 
Motion. — Elizabeth B., aged sixteen. Admitted to Bellevue Hos- 



CASE. 



173 



pital, January 29, 1861. Her father died of phthisis. In 1802 
she sprained her right ankle. The injury produced a chronic form 
of inflammation, and in two months it had increased so much 
that she could bear no weight at all upon it. She now moved 
about by hopping on the well (left) foot, and in about six weeks 





Fig. 117. 



Fig. 118. 



she had excited the same form of inflammation in that one as in 
the other. Two years after the first injury, when admitted to 
the hospital, her appearance was cachectic and miserable. The 
disease in her ankles had gone on to the formation of abscess, and 
several sinuses led into the joint, through which disintegrated 
bone had escaped. 

The gastrocnemius of both sides were so contracted as to ex- 
tend the feet nearly to a straight line with the tibiae. She could 
not bear the slightest pressure on either foot, and could not use 
crutches, as she could not poise herself on the ends of her toes, 
which were the only points that could touch the floor when in the 




erect posture. She was, therefore, compelled to move about upon 
her knees, as seen in Fig. 119, which also shows the sinuses con- 
necting with either joint. 

All active disease about the joints had subsided; but the dis- 



174 DISEASES OF THE ANKLE-JOINT. 

charge from the various sinuses was considerable, and, by probing 
them, several small pieces of bone escaped. 

On the 17th of February, 1864, in the presence of the class at 
Bellevue Hospital, I divided subcutaneously the tendo-Achillis 
on both sides, and restored the feet to their natural angle with the 
legs. Leather splints were then applied, to retain them in this new 
position until I could have a pair of instruments manufactured, 
which I am in the habit of using to extend the ankle-joint. {See 
Fig. 107.) 

On the 24th of February, just seven days after the section of the 
tendones-Achillis, these instruments were applied in the presence 
of the class at Bellevue Hospital, in the manner above described. 
{See page 164.) 

The sinuses were enlarged, and a seton of oakum drawn through 
the ankle-joint, as indicated in Figs. 108, 109, 110. A wad of 
oakum thoroughly wet in cold water was placed over each ankle, 
and secured by a firm roller. The screws were extended, and the 
difference in the appearance of the ankle before and after is well 
represented by comparing Figs. 110 and 111. 

These drawings were taken from life by Dr. Henry C. Eno, 
House-Surgeon of Bellevue Hospital, and are as accurate as any 
photograph could be. 

As soon as the instruments were properly adjusted, she stood 
upon her feet without the aid of crutch or cane, for the first time 
in two years, and without any pain whatever ; but, the instant the 
screws were shortened, the pain was most intense. 

She was directed to have the oakum around the joints kept 
constantly wet with cold water, and firmly supported by a bandage 
and changed as often as necessary. The seton was to be pulled 
through, and the soiled part cut off daily, and to be continued as 
long as any bone was exfoliating, until the matter should change 
from its sanious condition to a consistent pus, when it was to be 
removed, the wounds allowed to heal, and, if possible, passive 
motion made. If motion could not be attained, then the feet were 
to be anchylosed in their natural position, deeming that a stiff 
ankle was better than an amputation. 

The following notes of the case, copied from the hospital 
records, which were taken by Dr. Irving W. Lyon, House-Surgeon, 
now of Hartford, Connecticut, will show the progress and the 
result of the treatment : 



CASE. 175 

"February %&th. — She is very comfortable, and there is no 
pain about the ankles. 

" March 16th. — Has been out of bed most of the time since the 
operation ; but remained sitting at the bedside until to-day, when, 
with the aid of crutches to balance the body, she walked about, 
bearing her entire weight upon the feet, the extension made by 
the instrument being so perfect as to prevent pressure upon the 
joint-surfaces. 

"April 6th. — Apparatus removed from both feet, and motion 
made at the ankle-joints, which are perfectly free and movable, 
but pressure is yet very painful. The apparatus is reapplied. It 
should be stated that the patient was put upon the best diet the 
hospital could afford, together with cod-liver oil and iron. 

" 7th. — The adhesive plaster having become disarranged, neces- 
sitated its readjustment. It was now discovered that the sinuses 
had all closed completely ; but pressure while extension was off 
still gave her some pain. Her general health very materially im- 
proved. 

" July 20th. — All extension being removed, she is able to 
stand erect without pain in either ankle ; but attempts at walking 
occasion a considerable amount of pain and uneasiness. The 




Fig. 120. 



motions of the ankles are all unimpaired. Her health is thor- 
oughly restored, and she has not only grown taller since her ad- 
mission, but has also grown much more fleshy, and will weigh at 
least thirty pounds more now than in February. The splints are 
reapplied, and will require to be worn a little while longer to 
complete the cure." 



176 DISEASES OF THE ANKLE-JOINT. 

In a foot-note I find the following record :•.■"' It should be 
mentioned that since the 15th of March (the date of her com- 
mencement to walk upon the shoes) she has continued to walk 
upon her feet, bearing the entire weight of her body upon them, 
and only needed crutches to supply the . place of the muscles of 
the leg, which, on account of being confined by the apparatus, 
were unable to balance the body." 

Dr. Lyon left the hospital about this time, and I can find no 
further notes of the case on the records of the institution. She 
wore the instruments, however, until about the middle of Jan- 
uary, 1865, when they were permanently removed. The motions 
are almost perfect, and she can walk without pain. Fig. 120 is 
an illustration of her legs and feet after recovery. 

Case. Suppuration and Caries of the Ankle-Joint ; Opera- 
tion / Seton j Extension / Recovery with Motion. — In Jan- 
uary, 1855, I was sent for by Dr. L. C. Ferris to amputate 
the leg of Ella S., aged five years — for disease of the right 
ankle-joint. In March, 1854, ten months previous, she had fallen 
from a chair, striking her right ankle against the sharp corner 
of a bedstead. The injury was immediately followed by consid- 
erable swelling and very great pain. The pain soon subsided, 
but the swelling continued. 

For two or three weeks she seemed tolerably well, but at 
the end of that time she began to limp badly. She was then 
put upon crutches, and various lotions applied to the foot and 
ankle. 

The disease, however, continued to progress, her general 
health became much affected, with loss of appetite and sleep, and 
she was greatly emaciated. The limb was much smaller than the 
other, but the foot and ankle were swollen into a shapeless mass. 
In November she began to have repeated chills and hectic fever, 
and in the early part of December the ankle opened in several 
places, giving exit to a large amount of ill-conditioned or stru- 
mous pus. Her general health became much impaired, and in 
January, 1855, I was sent for to amputate the limb. Her suffer- 
ing was most intense; she would not permit the limb to be 
handled, and, until she was under the influence of chloroform, 
crepitus could not be detected ; several sinuses around the joint 
discharged quite freely a curdy pus mixed with a material very 
much resembling quince-jelly. 



CASE. 177 

A probe passed into one of these sinuses, just posterior to 
the internal malleolus, went into and through the joint, making 
its exit at a point in front of the external malleolus. A strip of 
linen (in default of anything better) was torn from the child's 
dress, passed through the eye of the probe, and drawn through 
the joint. 

A piece of firm sole-leather, cut to fit the front of the leg 
and dorsum of the foot, having been thoroughly soaked in cold 
water, was then applied over the top of the foot and secured by 
a nicely-adjusted roller ; the foot was firmly extended so as to 
separate the tibia and astragalus, and the roller then carried up 
the leg, over the leather, which, when dry, served to extend the 
joint and at the same time prevent all motion; This gave her 
great relief, and her limb could be moved with comparative com- 
fort. The child was put upon the most nutritious diet, with qui- 
nine, cod-liver oil, and iron. 

The dressings were removed and changed as often as they 
became soiled with pus, and, in the progress of the case, com- 
pression with sponges and cold water was resorted to. Her im- 
provement was most marked and rapid. At the end of a few 
weeks the instrument was applied, as in the other cases, and with 
the same happy results, enabling the patient to walk with crutch- 
es and obtain the benefit of out-door exercise, which added ma- 
terially to the improvement of her general health. 

The setons were retained nearly ten months, being gradually 
reduced in size as the bone ceased to exfoliate and the pus be- 
came more healthy, until for a number of weeks they were hard- 
ly larger than a single thread. When they were finally removed, 
the sinuses healed in a few days, and passive motion was com- 
menced as in the other cases. The patient continued to wear the 
instrument for nearly a year after she was perfectly well, as a 
means of prevention against accident, and then left it off entirely. 

It is now twenty-one years since this case was operated on, 
and she is as well in the one leg as the other, and the motions are 
almost as perfect. The foot is one size smaller than the other, 
and the leg a little shorter ; but the limb is perfectly developed, 
as represented in Figs. 121 and 122, which were taken from a 
plaster cast of her limb, and which also represent the cicatrices 
where the seton passed through the joint. Since recovery her 
limb has "continued to increase in size until it is now as well de- 
12 



178 



DISEASES OF THE ANKLE-JOINT. 



veloped as the other, and the motions are equally perfect ; in 
fact, she is the prize female skater of the city. 





Fig. 121. 



Fig. 122. 



Case. Caries of the AnHe-Joint / Seton / Recovery. — B. W., 
aged seven, of healthy parents, and whose brothers and sisters 
were all healthy, had himself always enjoyed good health, until 
in the summer of 1854, when he injured his left ankle by a fall. 

The joint swelled immediately, and was quite painful ; but 
still did not confine him to his bed until after four or five days. 
It then became so painful as to prevent motion, and for a number 
of days he was treated by perfect rest, and alternate applications 
of hot and cold water. As he made no improvement, after a 
few weeks his ankle was blistered, and this was repeated every 
eight or ten days for a great number of times, but without any 
improvement in his ankle. 

His general health became much affected, with loss of appe- 
tite and of sleep ; he became greatly emaciated, and suffered in- 
tense pain constantly, which was greatly aggravated at night by 
frequent spasms, or " jerkings of his foot " as he described it. 

The development of the leg and thigh on the affected side 
became arrested, the ankle and foot very much swollen and shape- 
less, a number of sinuses formed, leading into the joint, and the 
bones crepitated when the joint was moved. 



CASE. 179 

Dr. Valentine Mott saw him in July, 1855, and advised am- 
putation as the only means of saving his life. The mother, how- 
ever, would not consent to the operation, and I was called to see 
him in consultation with Dr. David Green in October, 1855. 
Several sinuses then existed, leading into the joint, through 
which the probe was passed without difficulty, but coming in con- 
tact with carious bone in almost every direction. 

On the 21st of October, 1855, I opened the joint freely on 
either side by connecting some of the sinuses, and found the joint 
carious throughout. 

Two setons of oakum were passed through the joint, the one 
laterally, and the other antero-posteriorly, and the foot extended 
by the instrument described in the case of Elizabeth B. As the 
seton was pulled through, a number of small pieces of bone were 
drawn out, entangled in its meshes. 

"When he recovered from the effects of the chloroform he 
could bear pressure on the foot without pain, and would permit 
it to be handled in any direction without complaint, although be- 
fore its application he would not permit it to be touched, and it 
was impossible to move it in any direction, even in the most care- 
ful manner, without giving him the most intense agony. 

He slept quietly the night after the operation, without any 
anodyne, although he had been compelled to use anodynes freely 
for many months, but never resorted to them again during the 
time he was under treatment. 

His general health began to improve almost immediately from 
the time of the operation and the application of the instrument, 
his appetite returned, and he was able to ride out in the open air 
with comparative comfort. The setons were pulled through 
daily and the soiled parts cut off ; and the whole ankle constantly 
surrounded with oakum saturated in cold water, and sustained by 
a tight bandage. 

For two or three months small pieces of bone were frequently 
found entangled in the fibres of the seton, when pulling it 
through ; but the discharge gradually diminished in quantity, be- 
came more consistent in character, and, as it did so, the setons 
were gradually reduced in size, until finally they were a mere 
thread or fibre. At the end of eleven months from their first 
insertion, they were removed entirely, and the sinuses closed up 
in a short time after, never to be reopened. 



180 



DISEASES OF THE ANKLE-JOINT. 



The extension was continued for nearly two years before it 
was removed permanently, although he had walked about for 
many months before the instrument was removed. As soon as 
the sinuses had become closed and he could bear moderate press- 
ure upon the foot, when the extension was off, without suffering 
pain, I commenced passive motions daily, by acting on the ante- 
rior and posterior screws alternately, thereby imitating the natu- 
ral motions of the joint. In about two years from the first op- 
eration, the instrument was removed permanently, when he could 
walk without difficulty, having considerable motion in the affected 
joint. This motion has very materially increased, and is now 
(twenty years after the operation) almost as perfect as the other. 
The foot is smaller than the other, and about half an inch shorter, 
but he supplies the deficiency by a thick sole inside his boot, and 
can run and skate without the deformity being detected. 

Drs. Mott, Stephen Smith, and other surgeons of this city, saw 
this case when under treatment, and therefore know that the 




Figs. 123 and 124. 



setons passed through the ankle-joint ; but, as there has been some 
question about it by others who have not seen the case, I have 
had his foot daguerreo typed on both sides by Mr. Gurney, and 
the cicatrices on either side, giving the entrance and exit of the 



DISEASE OF THE MEDIO-TAESAL JUNCTION. 181 

setons, show conclusively that they did pass through the ankle- 
joint. (See Figs. 123 and 121.) 

Disease of the Takso-Metatarsal Articulation. — Disease 
affecting the foot at this articulation is sometimes mistaken for 
disease of the ankle-joint, and must receive a passing notice. 

This articulation, like the ankle-joint, has its articular carti- 
lage, synovial membrane, and ligaments,, and the same causes 
that produce disease in one may produce it in the other. You 
may have then, a fall, blow, or sprain, producing an extravasa- 
tion of blood into the bone-cells beneath the articular cartilages, 
in the same*manner as occurs in connection with injuries of the 
ankle-joint. The extravasation instead of being absorbed may go 
on to suppuration, and osteitis and chronic softening of the bone 
result. The symptoms by which this condition is to be recog- 
nized are essentially the same as those which aid us in diagnosis of 
ankle-joint disease. The only method of arriving at a safe diagno- 
sis in these cases is to make a thorough examination (by means of 
pressure and compression, extension and twisting) of each and ev- 
ery articulation anterior to the ankle-joint. First make the ankle- 
joint immovable by firmly grasping the astragalus and os calcis, 
and then the foot is at your command to make motion at each 
articulation of the tarsus and also at the tarso-metatarsal junction. 
Pressure may be made directly over each articulation, but, when 
you wish to bring the articulating surfaces in contact, pressure is 
to be made, not by holding the leg and pressing the foot upward, 
but by holding the posterior part of the foot firmly, and crowd- 
ing the anterior part backward. If pain and tenderness can 
be developed at all by pressure, they can be developed in this man- 
ner. Then, by pressing each metatarsal bone backward in this 
manner, you will be able more accurately to detennine the point 
of disease. When it is determined which joint is involved in the 
disease, the patient should at once be placed upon his back in 
bed, and extension made from the toes by slipping an " Indian- 
puzzle " over each toe and attaching them to a cord fastened in 
the ceiling (see Fig. 125). The weight of the foot forms the 
counter-extending force. This treatment is applicable to dis- 
eases of all the articulations, anterior to that of the astragalus 
with the os calcis, where extension and counter- extension are re- 
quired. If the disease has gone on to suppuration, such extension 
will probably do no good, and, if absorption of the material poured 



182 DISEASE OF THE MEDIO-TAKSAL JUNCTION". 

out into the structures within and about the joint cannot be ob- 
tained by mean's of compression and iodine, an opening must be 
made, and the bony structures gouged and drilled until all ne- 
crosed or carious bone is thoroughly removed. When that is 




Fig. 125. 



done, fill the wound with Peruvian balsam, cover with oakum, 
and give firm support and compression to all the parts by means 
of a roller-bandage. In all these cases of caries of the bone, 
poulticing, the continued application of hot fomentations, and such 
like treatment, are injurious. They are injurious from the fact 
that they relax the tissues, give rise to engorgement of the blood- 
vessels, not only by inviting more blood to the parts, but by 
weakening the coats of the veins, and diminishing their power of 
contractility. Such treatment, therefore, tends to a more rapid 
and more extensive destruction of tissues. 

The parts are much more readily restored to their normal con- 
dition by giving proper support to the circulation, such as can be 
secured by a well-adjusted roller-bandage. This has a tendency 
to remove from the tissues infiltrated material, which, if permit- 
ted to remain, contributes largely to the subsequent destructive 
changes that may occur. "When a free outlet has been made for 



CASE. 



183 



the discharge of retained pus, firm compression is one of the best 
sedatives that can be employed. If the disease is within the 
joint, extension must be made before compression is resorted to. 
If the disease does not involve the articulating surfaces, then the 
extension will not be required, and this is a rule that is applicable 
to the management of all joint-affections. 

The following case illustrates the method of managing this 
disease : 

Case. — Catherine D., aged three years and three months, in 
May 1872, began to be lame in the left foot. The foot began to 
swell on the outer side, and over the tarso-metatarsal junction, 
which was purple in color, and "boggy" in feeling; not very 
painful to the touch. Several medical men have treated her for 
the past year by internal remedies. Condition on April 6, 1873, 
was as seen in Fig. 126. Tumor semi-fluctuating, purple, and hot. 

April 7th. — I covered the whole foot and leg with a thick 
flannel blanket, fitting it very nicely, and over it applied a plaster- 
of -Paris roller, with a sufficient number of thicknesses to make a 




Fig. 



Fig. 127. 



firm support. After the plaster was partially set, I cut a fenestra 
over the tumor, which immediately bulged up through the open- 



184 DISEASE OF THE MEDIO-TAESAL JUNCTION. 

ing, and was almost blue-black. A wad of oakum was placed 
over it for a compress, and a very firm roller carried over 4;he 
whole, Prof. W. H. Pancoast, of Philadelphia, being present. 

8th. — Removed roller and compress in presence of Drs. Pan- 
coast and Clay, and we were so much surprised at the improve- 
ment in color, and diminution in size of the tumor, that I de- 
cided not to open it, but to try to absorb it by pressure. Child 
had slept well, and was comfortable. 

9 th. — Still further improvement, but, an indistinct fluctuation 
being obtained, I made a number of small punctures, at the re- 
quest of Prof. Pancoast, discharging considerable blood. One 
of the punctures showing pus, I made a free incision and evac- 
uated a large quantity of broken-down cellular tissue, tough 
sloughs, and pus. The finger detected exposed bone at the outer 
portion of the scaphoid only. The wound was filled with Peru- 
vian balsam and oakum, and firm roller applied as before. 

10th. — Appearance much improved. 

June 20th. — Wound has cicatrized. Pressure continued. 
Plaster dressing removed. Toe elevated by adhesive plaster. 

August 12th. — Has continued to improve. Has not con- 
fessed to any tenderness for nearly or quite two months. Can 
walk on foot. Has a slight tendency to valgus. Adhesive plas- 
ter continued to retain foot in position. 

November 1, 1873. — Perfectly well, without deformity, and in 
robust health. (See Fig. 127.) 



LECTURE XV. 

DISEASES OF THE JOINTS. KNEE-JOINT. 

Anatomy of. — Structures affected by Disease. — Synovitis. — Disease of Ligaments. — 
Extravasation of Blood into the Cancellated Lamellae of the Bone. — Causes. — 
Early Symptoms, and those developed as the Disease progresses. — Pain over the 
Attachment of the Coronary Ligaments. 

Gentlemen : This morning we begin the study of diseases of 
the knee-joint. 

This joint is more subject to accidents than any other articu- 



ANATOMY OF THE KNEE-JOINT. 135 

lation in the body, on account of its more exposed position. I 
think it is even more liable to injury than the ankle-joint, judg- 
ing from the relative number of cases presenting themselves daily 
in my practice. 

Anatomy. — I will first briefly state the principal anatomical 
components of the knee-joint, a knowledge of which is essential 
to a full understanding of what I shall afterward explain when I 
come to speak of my views in respect to the origin, pathology, 
and treatment of diseases affecting its structures. 

The condyles of the femur above, the head of the tibia below, 
and the patella in front, are the bones that enter into the forma- 
tion of this joint. 

These bones are held in position by ligaments, some of which 
are exterior to, while others are within, the joint. Those which 
are exterior are the anterior or ligamentum patellse, the posterior 
or ligamentum posticum Winslowii, the internal lateral, the two 
external lateral, and the capsular. 

The ligaments found within the joint are the anterior or ex- 
ternal crucial, the posterior or internal crucial, the transverse, 
and the coronary. 

The two semilunar fibro-cartilages of this joint are also placed 
among the internal ligaments by some writers. 

In addition there are the ligamentum mucosum and the liga- 
menta alaria, which are merely prolongations from the synovial 
membrane. 

There are also two bursse : one situated between the patella 
and the skin, covering its anterior surface ; the other smaller in 
size, situated between the ligamentum patellse and the upper part 
of the tuberosity of the tibia. The posterior surface of the liga- 
ment is separated above from the knee-joint by a large mass of 
adipose tissue. 

Inflammation of these bursse sometimes gives rise to appear- 
ances very much resembling those presented by the so-called 
" white swelling" of the knee-joint. The synovial membrane of 
this joint is the largest and most extensive in the body, and forms 
various culs-de-sac in the process of enveloping the internal sur- 
faces of the joint. The articular surfaces of the bones are covered 
with cartilages which -subserve the purpose of " buffers," or cush- 
ions (the same as buffers upon railway-cars), to mitigate jars and 
concussions which otherwise might do serious injury to the inter- 



186 DISEASES OF THE KNEE-JOINT. 

nal structures. As the situation of the muscles which flex and 
extend the leg upon the thigh is important to be understood in 
applying extension, in the case of diseased knee-joint, more spe- 
cial reference to them will be reserved until we come to the sub- 
ject of treatment. 

Pathology. — All the structures which enter into the formation 
of the joint proper may become the seat of disease. We have, 
therefore, diseases affecting the ligaments, the synovial membrane, 
or, which perhaps most commonly leads to serious destructive 
changes involving the joint, injury of the deeper tissues, chiefly 
extravasations of blood. In a single case two or more structures 
may be involved ; or, what is much less frequent, the symptoms 
will indicate the presence of disease affecting one structure princi- 
pally. 

We shall, however, be obliged, in order to gain a clear idea of 
these different affections, to study them separately ; while at the 
same time you must understand they are likely to be associated. 

In this latter case the symptoms of each affection should, as 
far as possible, be separated from those of the others. 

Etiology. — The causes of disease affecting this joint are the 
same as those which produce disease in other joints, such as blows, 
sprains, contusions, over-exertion, strains and sudden check of 
perspiration, etc., etc. 

I now invite your attention to the diseases which affect the 
structures of this joint. 

First, then, respecting the synovial membrane. 

Synovitis. — This disease may be caused by wrenches, blows, 
punctures, exposure, or sudden changes of temperature after vio- 
lent exercise, or may be dependent upon constitutional affections, 
such as rheumatism, gonorrhoea, etc. 

The disease is usually considered under two heads, acute and 
chronic. 

If, then, a wrench, blow, or other cause, produces results chief- 
ly affecting the synovial membrane, an effusion of fluid soon 
takes place, which may be readily detected by the change pro- 
duced in the external appearance of the joint. The effusion dis- 
tends the synovial sac to a greater or less extent, and causes it to 
bulge out upon either side of the ligamentum patellae. 

If there is acute inflammation, it will be attended with great 
heat, swelling, and redness, sense of tension and throbbing, and 



SYNOVITIS. 187 

sooner or later intense pain. These symptoms will also be ac- 
companied by a general febrile movement. If the effusion into 
the joint is moderately abundant, distinct fluctuation may be ob- 
tained. When the effusion is considerable, the patella is lifted, 
so that when the leg is extended and elevated it is very easy to 
percuss this bone against the condyles of the femur, and produce 
an audible click. Under these circumstances it is almost impos- 
sible to mistake the nature of the disease. The sharp angular 
contour of the joint is obliterated, and there are present a general 
enlargement, rotundity, softness, and puffiness about the joint, 
which indicate the existence of an abnormal amount of fluid 
within the synovial sac. 

In the more chronic form of the disease we have effusion of 
fluid into the joint as before, but it is usually not so marked ; 
there is less tenderness upon pressure, and the pain is not so 
acute. If the disease has gone on to erosion of the structures 
within the joint, the erosion can be very easily detected by crowd- 
ing the articular surfaces together and slightly twisting them up- 
on each other, when the most intense pain will be produced. On 
the other hand, extension sufficient to separate the articular sur- 
faces, thereby removing all pressure from the inflamed membrane 
or the eroded tissue, relieves the pain at once. 

Ligaments. — If, upon the other hand, the ligaments are the 
parts chiefly involved, the amount of swelling which follows the 
injury will not be nearly as great as that which follows an injury 
of the synovial membrane. 

If the ligaments have been put upon such a stretch as to pro- 
duce rupture, even of a small number of their fibres, the point 
of rupture can frequently be detected by making careful and 
thorough pressure with the finger along the course of the liga- 
ments injured. 

Extension by stretching the ligaments at once gives the patient 
pain, and if the ligaments are the parts alone involved, compres- 
sion, crowding the articular surfaces together, by taking tension 
from the ligaments, affords instant relief. Extension and com- 
pression, therefore, in the manner indicated, are the chief means 
of recognizing the seat of the disease with reference to the syno- 
vial membrane and ligaments. 

Extravasation of Blood. — If the injury to the joint be the 
result of concussion, causing damage to the osseous structures and 



188 DISEASES OF THE KNEE-JOINT. 

extravasation of blood into the meshes of the bone, you will find 
great difficulty at times in making your diagnosis in the earlier 
stages. It is under these circumstances that we may have the 
beginning of a most serious disease, and yet no swelling what- 
ever about the joint be present ; there may, also, be absence of 
deformity and all appearances of injury, and for some time no 
abnormal heat can be detected by the hand, and it is in these 
cases that Dr. Seguin's thermoscope is invaluable. 

Your diagnosis now can only be made by compression, exten- 
sion, flexion, concussion, and the usual routine which a careful 
examination of a joint implies, and, as before intimated, you may 
be assisted by the thermoscope. 

Let us trace the history of such a case a little more in detail : 

In the great majority of cases a history of some injury, as a 
blow upon the knee, a fall upon the knee, a strain, or a sudden 
concussion, or anything of this nature, will be the first thing 
elicited when questioning the patient. The child may pay but 
little attention to his injury at first, and is soon at play again. 
After a while he may, and probably will, complain of some pain ; 
feels a little stiff when he first starts off, but goes better when he 
gets warmed up a little, like a spavined horse. This may com- 
mence within a few hours after the receipt of the injury, or it 
may be delayed several days. After resting for a short time he 
feels better, and is up and out at play ; within a few days he is 
down again ; he goes to bed, remains quiet for a few days, is 
probably obliged to remain quiet a little longer the second time 
than the first ; then he is up again and around as usual, and so 
he goes on, now down, now up, but finally gets so lame and stiff, 
or suffers so much pain, that the attention of the patient and 
parents or friends is especially attracted, and now off they go to 
the doctor for advice. 

The doctor, if unfamiliar with these cases, probably fails to 
determine the real condition, and, discovering no abnormal ap- 
pearance of the knee, tells the patient there is nothing the matter 
with it, and that he is " humbugging." Yet the patient is unable 
to walk without suffering a feeling of uneasiness, and more or 
less pain. In certain positions, perhaps, he can stand upon his 
leg, but the instant he bends it the pain will be very much in- 
creased. 

The patient thus dismissed, still disabled and becoming daily 



CAUSES. 189 

more incredulous, consults another doctor, who, taking for grant- 
ed what his predecessor said, confirms his decision, and so the 
patient is laid up, perhaps, four or five months, gets no relief, 
and the damage becomes irreparable. So, you will observe, the 
symptoms are sometimes exceedingly obscure, and let me advise 
you, when you have a case of this kind, to explore the joint in 
every possible direction, for the very fact of his having had a 
severe concussion affecting the part should be sufficient to make 
you thoroughly awake to the danger of the case. 

In the first stage of this condition, the injury to the bone 
may be exceedingly slight, just a light blow that has caused 
the extravasation of but one drop of blood — but the injured sur- 
face being constantly irritated, instead of the blood being ab- 
sorbed, inflammation supervenes, and at last suppuration takes 
place with disorganization of the whole joint. 

When the disease has progressed thus far it becomes very 
easy to make a diagnosis. The thing which you must first clear- 
ly ascertain is the locus in quo, as upon this depends the charac- 
ter of the disease as well as the nature of your treatment. You 
will, therefore, excuse reiteration, gentlemen, in my efforts to 
impress upon you the importance of determining whether the 
disease originates in the synovial membrane, in the ligaments, or 
in the cartilage proper. There is so little circulation in cartilage, 
however, that I doubt if disease of any kind ever commences 
here unless it be directly cut or torn ; although necrosis readily 
occurs in this tissue, as its vitality is so slight. 

In ordinary cases of so-called disease of the cartilage, the 
disease commences in the network of blood-vessels immediately 
underneath the cartilage. The cartilages are simply attached to 
the bones, have no circulation through their structure, except 
enough to vitalize them, and are not liable to serious injury. On 
the contrary, the blood-vessels which underlie these cartilages 
are very easily injured by blows or concussions, and are the fruit- 
ful source of chronic trouble. In the normal state the cartilages 
have very little sensibility, but when inflamed they are exceed- 
ingly sensitive. 

When the disease has gone to destruction of the cartilages 
and other structures within the joint, serious constitutional dis- 
turbance will be developed, as loss of appetite, sleeplessness, 
great emaciation, and perhaps hectic. The joint is usually enor- 



190 



DISEASES OF THE KNEE-JOINT. 



mously enlarged, and presents a striking contrast to the emaci- 
ated limb both above and below. The tissues about the joint are 
usually infiltrated with serum, and, consequently, have a boggy 
feel. They may, too, contain collections of pus, and this, by 
its burrowing, forms long, tortuous sinuses in various directions. 
The muscles will be " on guard," as already mentioned wdien 
speaking of diseases of the ankle-joint. The symptoms, when 
the cartilages become involved, are entirely different from any 
that have preceded them. The patient will suffer from spasms 
of the limb, and every now and then, particularly when asleep, 
cry out with a sharp, shrill scream. This is due, probably, to the 
fact that, while the patient is awake, the contraction of the mus- 
cles is more uniform, and the pressure is so constant as to be- 
numb the sensibility of the parts ; but, when sleep comes, momen- 
tary relaxation of the muscles takes place, some involuntary 
movement abruptly causes a sudden resumption of the contracted 





Fig. 128. 



Fig. 129. 



condition, and the diseased surfaces are snapped together violent- 
ly, causing intense pain. 

At this stage of the disease the tibia is usually subluxated 



CAUSES. 191 

backward and rotated outward. This has been caused by the 
powerful contraction of the biceps-cruris muscle, and, when 
present, gives to the joint that peculiar overhanging prominence 
so characteristic of the advanced stage of the disease, as seen in 
Figs. 128 and 129. 

"When the disease has become developed sufficient to give 
rise to the symptoms just enumerated, the case will present an 
unmistakable example of what is known as " white-swelling " 
or " scrofulous disease of the knee-joint." You may remember 
that the authorities in our profession from time immemorial have 
regarded destructive disease of the knee-joint, commonly called 
" white-swelling," as being essentially of constitutional origin. 
In other words, that it is scrofulous disease developing itself in 
a joint, the same as scrofula may develop itself elsewhere. 

Now, with all due deference to the opinions of the profes- 
sion, I understand this subject of scrofula, or "white-swelling" 
of joints, in a very different light ; and while I do not deny that 
the disease in question may and does occur in persons having a 
scrofulous diathesis, I shall prove to you that the scrofulous diathe- 
sis is simply an accidental accompaniment, and has no more to 
do with the development of the local disease within the joint than 
has the hemorrhagic diathesis, nor, in fact, as much, since a pecul- 
iar form of hsemorrhage into the cancellous tissue of the epiphyses 
from violence in some form is almost invariably the origin of this 
so-called scrofulous disease, or " white-swelling." 

Instead of accepting the usual designation of this disease, 
" white-swelling or scrofulous disease of the joint," I consider it 
to be an inflammatory softening of the epiphyses, and the result of 
the extravasation of blood, from rupture of blood-vessels situated 
immediately beneath their protecting cartilages. If this extrava- 
sation of blood into the meshes of the injured bones, for it gen- 
erally results from violent concussion, is not absorbed, it will de- 
velop a condition which will terminate in inflammatory soften- 
ing, that will lead directly to erosion and ulcerative destruction 
of the bones and their intervening cartilages. The synovial mem- 
brane, if not injured by the original concussion, or other cause 
which has given rise to the disease, will sooner or later take 
on inflammatory action from lying in contact with the parts of 
the joint involved. The disintegration and ulcerative destruc- 
tion of the injured portion of bone and cartilage are very much 



192 



DISEASES OF THE KNEE-JOINT. 



increased by the unremitting pressure exercised upon the diseased 
surfaces by reason of the contraction of the muscles surrounding 
the joints. This muscular contraction is reflex in character, and 
is excited by the presence of the disease within the joint. If this 
grinding of the injured surfaces together is not counteracted by 
extension and counter-extension, great destruction of the bony 
structures may take place, attended with unavoidable deformity. 

The outer condyle of the femur is the part which, almost ex- 
clusively, suffers from the unintermitting pressure, caused by mus- 
cular contraction. The constant traction of the single muscle 
attached to the outer side of the limb keeps up pressure at one 
particular spot, therefore causes interstitial absorption more rap- 
idly than the contraction of the four muscles on. the inner side, 
because of their varying points of pressure ; consequently the 
outer edge of the articulating surface becomes more rapidly dis- 
integrated, and gives rise to abduction, eversion, and rotation, 
after the manner illustrated by Fig. 130, taken from a plaster 
cast. In addition to my own observations, I have 
found this statement amply confirmed by examina- 
tion of many morbid specimens of this disease in 
the anatomical museums of Europe as well as those 
of this country. 

The apparent scrofulous condition of these pa- 
tients is simply in consequence of the exhaustion 
induced by the presence of a chronic joint-disease. 
If the disease is purely constitutional, it should be 
cured by internal remedies, but the use of internal 
remedies alone does not cure, and the case gradu- 
ally grows worse, unless something is done to reme- 
dy the local difficulty, and the trouble will finally 
kill the patient by the irritation and exhaustive 
suppuration produced. 

This is the usual termination of these cases when 
left to themselves, or when simply treated by the use of in- 
ternal remedies. Cure may, however, and does sometimes take 
place with the limb distorted and the joint anchylosed, and in 
many instances the distortion is most surprising, as seen by these 
models. {See Figs. 129 and 130.) 

Before leaving the study of the symptoms of this disease I 
wish to make special reference to pain. 




Fig. 130. 



PAIN OVER CORONARY LIGAMENTS. 193 

In many cases disease of a joint may be recognized by the loca- 
tion of the pain which accompanies it, as, for example, the pain in 
hip-disease is frequently entirely referred to the knee. In a case 
of chronic disease of the knee-joint, yon will always find the pain 
most acnte and most easily developed by pressnre at the onter por- 
tion of the head of the tibia, jnst over the insertions of the coro- 
nary ligaments. It is quite common to be able to make pressure 
over the whole surface of the joint without causing pain, if you 
will avoid this particular point ; but, the moment pressure is made 
over either the internal or external coronary ligaments, more espe- 
cially the external, intense pain will be produced. 

This pain is distinct from that caused by suddenly striking the 
head of the tibia against the condyles of the femur, and also, dis- 
tinct from that caused by the pressure upon the diseased articular 
surfaces produced by reflex muscular contraction. 

Pain produced by pressure over the situation of the coronary 
ligaments has a special value as a symptom, for, by its presence 
or absence, we are able to safely judge with regard to the con- 
tinuation or cessation of extension in the treatment, as pain can 
be developed at these points by a reasonable amount of pressure 
long after all other symptoms of joint-disease have passed away ; 
consequently, treatment should be continued until a reasonable 
amount of pressure over the attachments of these ligaments can 
be borne without producing pain. 
' We will next turn our attention to the subject of treatment. 



LECTUEE XVI. 

DISEASES OF THE JOINTS. KNEE-JOINT (CONTINUED). 

Treatment of Disease of. — Early Treatment. — Treatment in the Advanced Stages of 
the So-called "White-Swelling." — Apparatus for making Extension. — Mode of 
Application. 

Gentlemen : At our last lecture we studied the anatomy of 
the knee-joint, the diseases which may affect this articulation, 
their causes and early symptoms, and also the symptoms which 
13 



194: DISEASES OF THE KNEE-JOINT. 

are present when chronic knee-joint disease becomes fully devel- 
oped. To-day we will commence the study of — 

Treatment. — This part of our subject may be conveniently 
considered under two heads : 

1. Treatment for the earlier stages of the disease. 

2. Treatment when the disease has become so developed that 
the case requires extension and counter-extension, operative in- 
terference, etc. 

We shall speak first, then, of the treatment to be adopted 
when a case is seen early. 

The most important element in the treatment of injuries of 
the knee in the earlier stages is absolute rest ; no matter whether 
the ligaments or the synovial membrane is the part chiefly in- 
volved, or whether there is extravasation of blood beneath the 
articular cartilages or synovial membrane. You may secure such 
rest for the joint in any manner you see fit. In many instances 
it is, doubtless, the safer plan to carefully adjust a posterior splint 
made of sole-leather, felt, or other material, according to the con- 
venience of the surgeon, which shall extend along the upper por- 
tion of the leg and lower portion of the thigh, and hold the articu- 
lation and its surroundings perfectly fixed. Place the patient in 
bed at once and keep him there until recovery is well advanced. 

If the ligaments are the parts chiefly affected, you will not 
ordinarily have much difficulty with the case. Sometimes simply 
applying a bandage around the knee will give sufficient support 
and secure sufficient immobility to meet all the indications. The 
posterior splint and bandage will certainly fulfill every indication. 
The joint may be kept wet with hot or cold water, according to 
which affords the greater relief to the patient. After a few days 
have elapsed, when probably most of the acute symptoms will 
have subsided, you may write for a liniment, if the patient can- 
not be induced in any other way to give the joint a liberal 
amount of hand-rubbing and passive motion. These cases are 
usually slow in recovering, and it may be well to communicate 
this fact to the patient at the beginning. Treatment should con- 
tinue until pain and tenderness have entirely subsided. The 
principles of treatment are, perfect rest, hot or cold applications, 
according to the feelings of the patient, and firm compression. 
In a majority of cases, hot applications will be more agreeable. 
Compression can be secured by means of a roller-bandage, sponge 



ELASTIC COMPRESSION. 



195 



and bandage, or by means of the double India-rubber bag already 
referred to. The latter is the best mode, especially for the knee- 
joint. {See Fig. 131.) This bag can be partially filled with 




Fig. 181. 



either hot or cold water, as may be indicated, and, then being dis- 
tended with air, you have even compression, with the advantage 
of a hot or cold poultice as may be desired. 

When, however, the synovial membrane becomes involved in 
the injury, either alone or associated with injury to the ligaments, 
a much more serious condition of affairs is present, and will in a 
majority of cases require a more active plan of treatment. 

When the injury has been followed by effusion into the joint, 
next to absolute rest, elastic compression is the most essential ele- 
ment in the treatment. Place the patient in bed at once. It 
may be, and quite probably will be, necessary, in a majority of 
cases, to make some local depletion by means of leeches or wet 
cups before resorting to any measures for the purpose of pro- 
moting absorption of the fluid. The necessity of local depletion, 
and its amount, will be decided by the vigor, general health of 
the patient, and the degree of inflammatory action present, as 
manifested by increased heat about the joint, increased frequency 
of pulse, pain, and general constitutional disturbance. After local 
depletion, hot fomentations and elastic compression, secured either 
by means of a fine India-rubber bandage, or, still better, by the 
double India-rubber bag before referred to (see Fig. 131), will be 
of the greatest possible service. 

If absorption of the fluid does not take place rapidly under 



196 DISEASES OF THE KNEE-JOINT. 

this treatment, counter-irritation may be resorted to by applying 
blisters above and below the joint. Never apply yonr blisters 
directly over the knee-joint, but apply them above the capsular 
ligament, and below the ligamentum patellae. In addition, iodine- 
ointment may be applied over the joint, and covered with oiled-silk. 
Never use iodine locally in the form of tincture, for the reason that 
it is painful, the alcohol is soon evaporated, thereby leaving the 
iodine as a coating upon the skin which permits only a very small 
quantity to be absorbed.' After the first application, succeeding 
applications are of no service as far as absorption goes ; for they 
*simply facilitate the destruction of the cuticle, and until this layer 
is removed further absorption of the iodine cannot take place. 
The objection to iodine, therefore, in the form of tincture, is that 
it renders but little service except when its effect as an escharotic 
is desired; but, used in the form of an ointment, scarcely any 
pain is produced, no exfoliation of the cuticle follows, and there- 
fore absorption can go on, and in this manner the remedy renders 
continuous service. 

When the acute symptoms have subsided, great benefit may be 
derived by freely shampooing the parts, slightly lubricated with cos- 
moline, vasoline, or any substance which will permit the hand to 
glide over the surface freely without producing too much irritation 
to the skin. Friction should be applied in this manner with very 
great freedom for from twenty minutes to half an hour at each 
sitting ; and, while one hand is made to do rubbing around the 
joint, the other hand should rub up and down upon the limb 
above the joint, thereby greatly facilitating the absorption of the 
effused fluid. If the case does not yield to this treatment, and 
the effusion increases so as to make tension sufficient to paralyze 
the absorbent vessels, it may be necessary to aspirate the joint 
and remove all the fluid possible. In many instances, if only a 
small quantity of the fluid is removed, the tension upon the 
absorbent vessels will be relieved to such an extent that the 
remainder may be absorbed by the means already mentioned. 
This is an application of the same principle that governs us in the 
management of certain cases of ascites ; namely, first, removing a 
portion of the fluid from the abdominal cavity in cases where great 
distention is present, and then resorting to diuretics, hydragogue 
cathartics, etc., for the removal of the remainder. 

Before the aspirator came into use, it was the custom to make 



PUISTCTUEE of the joixt. 197 

a valvular incision through the integument and structures be- 
neath it, letting the blade glide along until the joint was reached, 
and then plunging it iu, and giving vent to the imprisoned fluid. 

"When the fluid is serous, or of such character that it can flow- 
through the canula, aspiration can be employed with much greater 
advantage than incision with the knife. Sometimes, however, it 
happens that the fluid contains so much flocculent material that 
it cannot be removed by the aspirator. Under such circumstances 
no hesitation need be made with regard to opening the joint, 
and giving free discharge to the fluid. As a matter of course, 
puncturing this joint, as puncturing any other joint, is a very 
serious and, if not properly managed, a very dangerous thing to do. 

If you puncture this joint for the purpose of withdrawing the 
excessive amount of synovial fluid, and^ puncture it in such a 
way as to admit air, the consequence will be very serious indeed, 
because decomposition of the contents of the synovial sac will take 
place and you will have excessive fever, and suppuration will be 
set up. I am not afraid of air ; but I fear imprisoned air. There- 
fore, if compelled to make an opening which will permit the en- 
trance of air, at once make it large enough and in such a position 
that the air can get out again. I wish to be distinctly understood 
about this matter, and I want to impress it clearly on your minds, 
that the success of the operation depends almost entirely on 
keeping out the air when you puncture a joint. With this pre- 
caution there is no danger whatever connected with it. When 
you have punctured the joint and are about to withdraw the canula, 
no movement whatever of the joint must be allowed to occur until 
it is, so to speak, hermetically sealed and locked. You must have 
for this purpose some plaster-of -Paris, leather, or starched band- 
age — anything on earth, in fact, which will, when applied on the 
posterior aspect of the limb, promptly solidify and prevent the 
least movement. Let me, also, impress upon you not to allow 
the joint to move until the external opening is perfectly united. 
If you do, the air will be sucked into the synovial sac in spite of 
your valvular subcutaneous opening. This precaution is very 
simple, but is most important for the safety of the patient. 

If, on puncturing the joint, you find the fluid which it contains 
has already begun to change, has become converted into pus, then, 
instead of leaving it with a simple puncture, make a free incision, 
always cutting at the most dependent part of the sac, so that there 



198 DISEASES OF THE KNEE-JOINT. 

shall be no possibility of secretions being pocketed or otherwise 
retained. 

As soon as it is discovered that reflex contractions are taking 
place, which if not overcome will terminate in the production of 
serious deformity, mechanical appliances which afford extension 
and counter-extension must be resorted to, and are always required. 

Such reflex contractions will not only produce deformity, but 
will greatly aggravate the pain by bringing the diseased articulat- 
ing surfaces into contact. Extension and counter-extension may 
therefore be necessary for the relief of pain incident to such mus- 
cular contractions. When extravasation of the blood has taken 
place at any point beneath the articular cartilages, which can be 
discovered only by firm compression of the articulating surfaces 
of the tibia and femuc in all possible directions, and also upon 
the patella, and especially making pressure immediately over the 
insertion of the coronary ligaments, you should immediately re- 
sort to the treatment already indicated, perfect rest, and firm 
compression with the sponge and roller-bandage or double India- 
rubber bag, after extension and counter-extension have been ap- 
plied. 

By the use of this bag which I now show you (see Fig. 131), 
the pressure on the joint is maintained evenly, and there is no 
danger of pressing the ecchymosed surfaces of bone against each 
other. Pressure by this means is to be continued until absorption 
of the effused blood takes place, and until the patient can bear con- 
cussion of the bones, the tibia and femur, against each other. 

When the disease of the joint, no matter in what particular 
tissue it originated, has advanced to a condition of suppurative 
disorganization of the structures, it is often attended with grave 
constitutional symptoms, such as sleeplessness, loss of appetite, 
great pain, and irritative fever. This condition is then generally 
spoken of as " white-swelling of the knee-joint." 

Such a condition will require a much more systematic and 
prolonged course of mechanical and surgical treatment than has 
been indicated for the prevention of this advanced stage of the 
disease. One great indication in the case now is, to place the 
patient in a condition such as will permit him to have all the 
advantages of fresh air and sunlight, and at the same time be 
relieved of all irritation attending the constant attrition of the 
diseased articular surfaces. It is in this particular form of the 



EXTENSION AND COUNTER-EXTENSION". 199 

disease, therefore — inflammation of the articular tissues — that 
extension is of the utmost importance. I regard this principle as 
one of such moment that, were its practical application inter- 
fered with by participation of the tissues in the inflammatory 
action, I should have no hesitation in cutting them, for the 
tendons will heal by the time the articular surfaces have resumed 
a healthy condition. 

Extension is especially important here, for the reason that, 
even when the tendons are not inflamed, the irritation produced 
by the inflammation within the joint invariably excites reflex 
action. The muscles contract, and thereby increase the compres- 
sion upon the already suffering tissues within the joint, and if 
continued produce serious deformities, according to the direc- 
tion in which the predominating set of muscles are drawing. 

In looking over Sir Benjamin Brodie's works, I find he 
recommends positive rest, and that is all. But you may do this 
— you may rest the joint in splints — but you do not do all that is 
required. You may keep the limb perfectly still, and locked up 
in every conceivable way, and yet you do not overcome the 
tendency of the muscles to contract — you do not prevent the 
reflex action. 

The result is the diseased surfaces are brought in contact ; the 
pain is continuous, and the parts pressed upon undergo interstitial 
absorption. But when you give extension to these limbs, thus 
locked up by disease, you will give the patient instant relief. 

I have been very successful in the treatment of this class of 
cases, and I attribute my success, in a great measure, to the fact 
that extension has been made a leading feature of my treat- 
ment. 

Some people imagine that this extension means hitching on a 
pair of horses, and subjecting the patient to a sample of what 
some of the old-time martyrs endured. But you have seen in 
our clinical practice that all we want is simply enough extension 
to overcome the reflex contraction of the muscles, and to separate 
the diseased surfaces of the joint so far as to remove the pressure 
occasioned by their contraction. By doing this you relieve the 
pain. Of course, if you extend too much you injure instead of 
benefiting the patient ; for, anything that has power to do good, 
has power to do harm, if indiscreetly used. 

Remember, then, in the first place, that rest — permanent rest 



200 



DISEASES OF THE KNEE-JOINT. 



of the tissues involved — is an essential part of the treatment. In 
addition to rest, extension, constantly and persistently employed 
until the patient is cured. Besides rest and extension, you want 
compression; but this must be employed after the two former, 
for compression of the joint, without first obtaining rest and 
extension, would aggravate the difficulty. 

These indications are met by an instrument that I devised 
several years ago, which you here see. (See Fig. 132.) 




Fig. 132. 



This instrument should be applied the moment there is any 
evidence that the disease has affected the articular structures, or 
reflex muscular contractions have been excited, which, if per- 
mitted to continue, will produce deformity. 

When the joint is filled with liquid acting like a foreign body, 
as in the ankle-joint, it is advisable to give the patient the benefit 
of the doubt as regards being able to secure absorption, trusting 
that fixation of the joint in such a manner as will relieve the pa- 
tient of all pain, and remove all pressure from the diseased sur- 
faces, will diminish the amount of irritative fever, and give us 
the opportunity to build up and invigorate the general system, so 
as to render the absorption of the fluid practicable. 

As long as there is any hope of preserving the joint intact, 
this instrument should be applied. The instrument consists es- 
sentially, as you see, of two sheet-iron bands or collars, connected 
by two bars so constructed that they can be made longer or 
shorter as required. The bands are about an inch in width, 
have a joint behind, and slots and a pin for fastening in front. 

The hinge-joint at the posterior portion of the band that is to 



KNEE-EXTENSION APPAEATUS. 



201 



surround the leg is made by cutting straight across the band, and 
then fastening the pieces in the proper manner for forming a 
joint. The hinge-joint at the posterior portion of the band that 
is to surround the thigh is made by cutting out a V-shaped piece, 
and then fastening the pieces in the proper manner for forming 
a joint. This V-shaped piece is removed for the purpose of se- 
curing a smaller circle at the lower edge of the band than at the 
upper, which will better adapt it to the natural tapering shape of 
the thigh. The band which surrounds the leg should be immov- 
ably attached to the side-bars. The band which surrounds the 
thigh should be attached to the side-bars in such a manner (by a 
single rivet or hinge) that it can be tilted about at pleasure, 
which permits the use of the instrument when the leg is flexed 
upon the thigh at a slight angle. The bars which connect these 
bands or collars are divided into two pieces, one of which carries 
the cog and the other the ratchet, by means of which extension 





Fig. 133. 



Fig. 131. 



is to be made. The ratchet is moved by means of a key, and in 
this manner any amount of extension desired can be readily ob- 
tained. {See Fig. 133.) 

So much for the description of the instrument, and now we 



202 



DISEASES OF THE KNEE-JOINT. 



come to the method of its application. In the first place, if the 
limb is much distorted, the leg flexed upon the thigh, and perhaps 
the tibia partially luxated backward, as illustrated in Fig. 134, ex- 
tension must be made, while the patient is in bed, until the limb is 
brought to nearly a straight position, before the instrument is ap- 
plied. Such extension previous to the application of the instru- 
ment (as already indicated in cases of long standing when sublux- 
ation is present) must be made in two directions : 1. From the 
foot and lower portion of the tibia by means of weight and pul- 
ley, with the limb placed in such a position that the patient can 
endure the extension without suffering pain ; and, 2. From behind 
the tibia upward and forward. {See Fig. 135.) It is all-impor- 
tant that such double extension be applied, for more than likely 
the direct extension from the foot will give pain until the second 
line of extension is brought to bear. This double extension can 
be applied to a limb, and continued when the limb is placed in 
the proper position, so that the extending force is brought to bear 
at a proper angle without giving pain. This proper angle must 
be found, which can be easily done by moving the limb about ; 
and the extension should not be made until such position has 
been obtained. When this has been done, and the extension is 




Fig. 135. 



properly applied, the pain is immediately relieved. The apparatus 
for making the direct extension is the ordinary extending appa- 
ratus, consisting of adhesive plaster, roller-bandage, cord, and pul- 
ley and weight. {See Fig. 135.) 

The second line of extension can be made by means of a cord 
fastened to the ceiling, or other apparatus sucli as the ingenuity 



APPLICATION OF THE INSTKUMENT. 



203 



of the surgeon may devise. When the double extension, the two 
lines being made to gradually approach each other, has brought 
the limb into nearly the straight position, it is ready for the in- 
strument, which is to be applied in the following manner: 

Surround the leg with strips of adhesive plaster about one 
inch in width placed, lengthwise, and reaching from the top of 
the tibia down to the ankle-joint, and secure them with a roller- 
bandage from the top of the tibia down to the point at which the 
lower band of the instrument is to be applied, leaving four or 
five inches of the lower extremities of the plaster loose, fastening 
the bandage with stitches. ISText, surround the thigh with strips 
of adhesive plaster of about the same width applied in the same 
manner and extending lengthwise upon the thigh from the lower 
extremity of the femur nearly its entire length. Secure these 
plasters with a nicely-adjusted roller bandage from the knee up- 
ward to the point where the upper band of the instrument is 
to be applied, leaving the remaining portion of the plaster loose. 
(See Figs. 136 and 137.) 

The limb is now ready for the application of the instrument. 






Fig. 136. 



Fig. 137. 



Fig. 138. 



Place the instrument on the limb in such a manner as to 
bring the side-bars upon the same plane with the condyles of the 
femur, and place it in the hands of an assistant, to be held 
steadily in that position. The collar embracing the leg should be 
closed so as to closely engage the leg, but not sufficiently tight to 



204 DISEASES OF THE KNEE-JOINT. 

interfere in the least with a free return-circulation. Now re- 
verse the loose extremities of the pieces of adhesive plaster, bring 
them snugly over the collar and upon the leg, where they are to 
be secured by a few turns of the roller-bandage which has just 
covered the foot and secured the upper portion of the plaster. 
Next press the lower collar down into the plasters which now 
engage it, and then secure the upper band about the thigh. This 
band you must recollect is attached to the side-bars in such a 
manner, like a swivel, that it can be tilted sufficiently to come in 
contact with the thigh and produce serious results, by pressure, 
unless it is properly secured. This can be done by taking one 
piece of plaster oehind and another in front, at points exactly 
opposite upon the circumference of the limb, and reversing them 
in such a manner as to bring equal traction upon the collar pos- 
teriorly and anteriorly, which will balance it so that, its edges 
will not come in contact with the thigh at any point. The band 
is first closed around the thigh only sufficiently tight to be com- 
fortable. When this is done the remaining strips of plaster can 
be reversed without causing the edges of the collar to make press- 
ure at any point, and all are then secured with a roller-bandage. 
(See Fig. 138.) Now we have the instrument fastened at its 
lower and upper extremity in a manner which will enable us to 
make extension and counter-extension to any degree required. 

This is done by means of the key and ratchet on the bars of 
the instrument. The amount of extension and counter-extension 
required is that which is sufficient to produce perfect relief from 
all pain, or the possibility of produciug pain by making concus- 
sion or pressure. This can be obtained by extending the bars 
first on one side and then on the other, until the desired amount 
of extension is reached, when the instrument is locked by the 
slide and retained there. 

An important point to be remembered is, that you can do a 
good deal of harm by making too much tension upon the lateral 
ligaments. The point to be aimed at is, to make just sufficient 
extension and counter-extension to give perfect relief from all 
pain by pressure upon the articular surfaces of the joint, and no 
more. 

If too great tension is applied, the patient will complain of a 
sense of discomfort. In either case, therefore, the countenance 
and feelings of the patient are to be your guide with reference 



APPLICATION OF THE INSTEUMENT. 205 

to the amount of extension to be applied. When the dressing is 
first applied, the plasters and bandages may so yield that the pa- 
tient, soon after their application, again suffers pain. When this 
happens, extension is to be immediately increased, until the pa- 
tient gives no response in his face upon the application of con- 
cussion or pressure. Now we have an apparatus applied to the 
limb, as you will see, which is competent to remove all pressure 
from the articulating surfaces of the joint. 

If there are present any evidences of inflammatory action 
about the joint, such as may demand active treatment by leeches, 
cold or hot applications, counter-irritation, etc., your command of 
the joint is perfect, and such applications can be made as may be 
deemed necessary. If you wish to apply hot or cold, it can be 
done by means of a sponge and roller-bandage. Just here there 
is an essential element in practice which must never be lost sight 
of ; for, if we should leave the limb as you see it with the in- 
strument applied, so as to make extension, and do no more for it, 
it would be ruined. The boggy, infiltrated connective tissue 
which everywhere surrounds the joint, if left without proper 
support, would become more and more engorged by the bandages 
which have been applied until strangulation would take place, 
gangrene ensue, and the knee-joint and patient go together. 

Compression, then, is an essential element in the management 
of these, cases and must never be neglected, but is never to be 
applied until after the extension is properly adjusted. Then you 
must firmly strap the joint, first filling the popliteal space with 
cotton, old rags, or sponge, and, commencing below with the adhe- 
sive strips, go upward, shingling the joint, as it were, in such way 
as to leave no point uncovered. These adhesive straps must also 
be applied in such a manner as will make uniform pressure over 
the joint. You will not, however, strap the joint after this fash- 
ion until your instrument has been applied, and extension and 
counter-extension have been made ; for, if applied before this has 
been done, the skin will be folded into pleats, and strangulation 
and gangrene may result. 

Again, we wish to continue the double extension which has 
been applied to bring the limb into the present position, and this 
can be accomplished by carrying the bandage (after covering the 
knee just strapped) between the bars of the instrument and the 
\eg, then over the bars, and under or behind the tibia in such 



206 



DISEASES OF THE KNEE-JOINT. 



a way as to crowd the head of the tibia forward ; and in the 
same manner above the knee, applying the bandage in front of 
the femur so as to crowd its lower extremity backward. In this 
manner you will at once see that we are putting into practical ap- 
plication, upon the instrument, the same principle we were apply- 
ing when the double extension was used while the patient was in 
bed. 

JSTow, if the patient be an adult, he will probably require the 
aid of crutches in walking, otherwise too great a strain will be 
brought to bear upon the plasters which hold the instrument in 
place ; but, if a child like the one before you, he may go about 
without their assistance. As you see, he walks without any limp- 
ing, by keeping his well knee stiff to match the diseased one, and 
has no pain whatever when the instrument is properly adjusted. 
Compare his present condition with what it was an hour since 
{see Fig. 134), and no argument is necessary to prove the value 
of the treatment {see Fig. 139). 




Fig. 139. 



Artificial support for these diseased knee-joints (which, if 
properly applied, removes all pressure from the articulating sur- 
faces, and gives the patient perfect comfort ; which can be worn 
for months, and, if need be, without changing) permits the pa- 



RE APPLICATION OF INSTRUMENT. 207 

tient to be out-of-doors, where he can obtain fresh air, the influ- 
ence of sunlight, and, in short, to avail himself of all the hygienic 
measures which are to contribute so largely to his final recovery. 



LECTUKE XVII. 

DISEASES OF THE JOINTS. KNEE- JOINT (CONTINUED). 

Treatment of Chronic Disease (continued). — Kemoval and Reapplication of the In- 
strument. — Passive Motion. — Protection of the Joint after the Splint has been 
removed. — Shall the Joint be permitted to anchylose ? — Cases. — Operative Inter- 
ference in Extreme Cases. 

Gentlemen : In our last lecture we studied the method of 
treatment in the earlier stages of the disease and the mode of 
applying the instrument used for making extension in chronic 
disease of the knee-joint, and to-day we will first answer the 
questions, How often is the instrument to be removed and reap- 
plied, and how long must it be worn ? 

It may be necessary to reapply it very often, if it has been 
carelessly or uu skillfully applied, or if poor plaster has been used. 
For it must be reapplied just as soon as it fails to meet the indi- 
cations, no matter if it is every hour in the day. 

But, when the instrument is carefully adjusted, good plaster is 
used (Maw's moleskin), the skin clean and dry, and the plaster 
not warmed too much before it is applied, it may remain perhaps 
for three months, or even longer. 

As long as the instrument maintains the proper amount of 
extension it need not be changed. When it does become neces- 
sary to readjust it, you must remember never to attempt to ap- 
ply new plaster over the layer of dead epidermis which will be 
found if the plaster has been worn for a long time, for you might 
as well fresco an old scaly wall. 

The instrument must be worn until the joint is well ; until 
concussion, produced by bringing the tibia and femur together, 
does not cause pain ; and until pressure over the coronary liga- 
ments is painless. When this can be done, you may remove the 



208 DISEASES OF THE KNEE-JOINT. 

instrument and commence the passive movements and manipula- 
tions that are to restore motion to the joint, and complete the 
cure. This part of the treatment requires time. When the pa- 
tient has reached this point he is upon the highway which leads 
to complete recovery, and perfect success may be obtained if we 
are not too hasty in our endeavors to restore the limb to its nor- 
mal condition. It is just here, not infrequently, that a very great 
mistake is made. The end of the disease has been reached, but 
the repair of damage done has to be accomplished, and now the 
surgeon should recollect that perfect restoration can only be ob- 
tained by cautious and gradual advances. The old saying that 
" the longest way round is the surest way home " is particularly 
applicable to the management of these cases from this point on- 
ward. When passive movements are commenced they should 
not at any time be carried beyond the point of producing pain. 
You will hold one hand beneath the knee-joint, as you now see 
me doing, while with the other the leg may be carefully flexed 
upon the thigh, until you have reached the point at which pain 
is produced, but never carry it farther. If this treatment is 
practised regularly and systematically every day, you will find 
that flexion can be slightly increased each time, and thus you 
are to go on until complete flexion is obtained. You will also 
find that such passive movements will be much more success- 
ful if accompanied by a great deal of hand-rubbing. I do not 
believe we have given the consideration to gentle but thorough 
friction with the hand which its importance demands. There is 
no more efficient means for reducing capillary congestion and 
removing infiltrated material from the tissues than gentle, free, 
but careful rubbing with the hand. There are those who pretend 
to possess remarkable healing power in their hands, and claim to 
be able to perform wonderful cures by rubbing, etc., but no one 
of any sense believes one individual possesses any special power 
over another in this direction ; it is all humbug ; and yet many 
joints, in which partial anchylosis may be present as the result 
of disease or from simple rest of the joint, are abandoned by 
surgeons and fall into the hands of these pretenders, who effect 
marvelous cures. These pretenders may be scientific by accident, 
perhaps, and one cure will be sufficient to give them a life-long 
reputation and to do the profession and society an immense 
amount of injury ; but there is no reason why any surgeon should 



AFTER-TREATMENT. 209 

not possess the same power, and afford the same benefit to his 
patients as any of the most successful of these traveling manipu- 
lators. 

The occasional application of electricity may also be of service. 
But, in resorting to any or all of these measures, the great point to 
be taken into consideration is, to carefully guard against carrying 
them to such an extent as to redevelop inflammation. If at any 
time you have been a trifle indiscreet, and have carried your pas- 
sive movements too far, or have made your manipulations too 
freely so as to cause pain which shall last for more than twenty- 
four hours after the manipulations have ceased, or to give rise to 
the slightest elevation of temperature about the joint, place the 
patient in bed immediately, elevate the limb, apply cold, and 
secure absolute rest until all inflammatory action has subsided ; 
after which your passive movements can be renewed. Passive 
movements short of exciting inflammation may be made as freely 
and as often as desired, without danger. 

In all these cases, no matter in how favorable condition the 
joint may be when the instrument is removed, it is necessary for 
a time to apply some kind of apparatus to protect the joint against 
accidents, such as falls, trippings, etc., and also to prevent too free 
motion of the joint. For this purpose a piece of ordinary sole- 
leather answers very well. Take a piece of sole-leather about 
the same length as the instrument which has been employed, and 
sufficiently wide to embrace one-half or two-thirds of the limb, 
dip it in cold water, and, when it has become thoroughly flexible, 
mould it to the posterior surface of the limb, and secure it with a 
bandage. The leather when wet can be moulded to the limb so 
as to fit it perfectly, and, when dry, it gives firm, unyielding sup- 
port, and at the same time can be easily removed and reapplied at 
such times as you may desire to practise passive movements and 
hand-friction. 

Again, firm support may be given to the limb, and at the same 
time motion of the joint allowed within the limits of safety, by 
the use of the instrument which I now show you, made by Mr. 
Darrach, of Orange, New Jersey. (Fig. 140.) It consists of 
leather rawhide moulds, fitting the back part of the thigh and 
leg, and buckled in front. 

These are connected by lateral steel bars, jointed at the knee ; 
the flexion and extension are made by means of a ratchet-and-cog 
14 



210 



DISEASES OF THE KNEE-JOINT. 



wheel ; at the back, there is also a spiral spring on the extending 
rod which permits limited motion when walking. 

A knee-cap retains the limb in its proper position in the splint 
when motions are made. 

There are some cases of chronic disease of the knee-joint, 




Fig. 140. 



however, in which anchylosis is the best possible result that can 
be obtained. Of course the question, whether you permit anchy- 
losis to take place or not, must be fully decided, i'f possible, before 
you resort to passive movements. In some cases it may be im- 
possible to' decide this question until passive movements have first 
been tried. 

If, after the application of the instrument, which shall main- 
tain a constant extending and counter-extending force, the joint- 
disease goes on favorably and steadily toward a cure, and shows 
no disposition to recurrent attacks, you may reasonably expect 
that, when the inflammation has entirely subsided, passive move- 
ments and other necessary manipulations will restore the use of 
the joint completely. 

On. the other hand, if there is a lurking tendency to the de- 
velopment of inflammatory action, in consequence of nearly every 



ANCHYLOSIS OF THE JOINT. 211 

effort made for establishing a cure, whether it be in the way of 
passive movements or the ordinary means for affording extension 
and counter-extension ; or, in some cases, apparently independent 
of any exciting cause ; in short, the diseased joint is frequently 
taking on a new inflammatory action, and behaves badly, you may 
have grave apprehensions respecting the future mobility of the 
joint, and may reasonably regard anchylosis as a very favorable 
result. There are some cases in which the disease progresses 
reasonably well until passive movements are resorted to, and then 
there is at once an almost constant tendency to new inflammatory 
action, in consequence of such movements, however carefully they 
may be made. Such cases require to be managed with the greatest 
caution, and are very unpromising with regard to final results, as 
far as motion is concerned. 

If carefully watching the progress, the behavior, and the 
tendencies of the case, bring you to the conclusion that the best 
result that can be obtained is that of anchylosis, let the anchylosis 
take place with the limb in a straight position. The old rule has 
been to secure anchylosis, in cases in which it was unavoidable, 
with the leg flexed upon the thigh at a slight angle ; but I am 
opposed to this rule, for the reason that, when anchylosed at this 
angle, the solidification is very insecure, and is liable at some 
future date to give the patient trouble. This question, however, 
will be more fully considered when we come to speak on the sub- 
ject of anchylosis. 

We have now completed the study of the essential features of 
treatment, both when the case is seen soon after the receipt of the 
injury, and also when chronic disease of the joint is fully estab- 
lished. 

The following case illustrates the disease and the treatment 
we have just been studying : 

Case. Chronic Synovitis of Knee-Joint, with Angular Contrac- 
tion mid probable Ulceration of Cartilages ; Tenotomy; Exten- 
sion by Splint ; Recovery. — Ann H., Jersey City, aged fourteen; 
father healthy, but mother died of phthisis ; fell, when nine years 
of age, on the sidewalk, striking her right knee on the curbstone, 
producing a severe inflammation of the knee-joint, which confined 
her to her bed for some weeks. Leeches, cups, poultices, and 
the usual antiphlogistic treatment, were adopted for som,e time, 
and finally resulted in recovery. For nearly a year she consid- 



212 DISEASES OF THE KNEE-JOINT. 

ered herself well, although she always had more or less pain in 
the knee-joint, after any very severe exercise; but it was not 
thought of sufficient importance to call for professional advice, 
as it generally subsided by a few days' rest, although her father 
had applied a blister to it occasionally. When about twelve years 
of age she again sprained the joint by slipping on an orange-peel, 
which produced the most intense pain, immediately after the acci- 
dent, and which continued until the time I saw her, two years 
after. She had been cupped and leeched repeatedly ; blisters 
and issues had been applied for some months, but all without 
any benefit, and finally the agony became so intense and the 
patient so much prostrated, that the disease was decided to be 
incurable, amputation advised, and I was sent for to perform it. 
Dr. Wm. K. Cleveland went with me to assist in the opera- 
tion. We found the girl sitting on a chair, with her knee flexed 
at an acute angle, the foot resting on a stool a little lower than 
the chair on which she sat, her body strongly bent forward, and 
both hands firmly clasped around the limb just below the knee 
to prevent, as far as possible, any movement at the joint; at 
the same time she appeared to push with considerable force, 
and stated that that was the only way in which she could get any 
ease. Her father stated that she had sat in that position most of 
the time — day and night — for the past three months ; she would 
not let go her leg even to feed herself, and they had therefore to 
feed her. Whenever her position was changed, either to be put 
in bed or to attend to the necessary calls of nature, it produced a 
paroxysm of the most intense pain, which frequently lasted some 
hours, and could not be relieved by any anodyne, although she 
took morphine in very large doses constantly. Her knee was 
very much enlarged, almost transparent, and the irregular con- 
tours quite defaced by the general rounding out of all the parts. 
The limb below and above the knee was very much smaller than 
the opposite one. Her pulse was 160 ; face very pale and emaci- 
ated, and her countenance bore the most marked expression of 
intense suffering that I have ever witnessed. It was impossible 
to walk about the room, or in any way jar the floor, without caus- 
ing her to scream in agony. 

When Dr. Cleveland took hold of her foot to move her in posi- 
tion for the operation, she seized him by the arm with her teeth, 
and held on with the grip of a tigress, until I grasped her limb 



CASE. 213 

above and below the knee, and by firm extension and counter- 
extension, to separate the bones from each other, gave her such 
relief that she let go her hold upon his arm. As long as I con- 
tinued the extension she seemed comparatively quiet, and said it 
gave her great relief ; but the instant I relaxed it at all she 
screamed in agony. This fact decided me not to amputate, until 
she had had the benefit of extension fairly tried. It was impossi- 
ble to do this efficiently without first dividing the hamstring mus- 
cles, as the leg had been so long contracted. I therefore held the 
limb still while Dr. Cleveland put her under the full influence of 
chloroform, when I divided the outer and inner hamstring tendons 
subcutaneously, covering the wounds immediately with adhesive 
plaster and a roller. By a very slight force the limb was at 
once made almost straight. A long strip of adhesive plaster, 
about four inches in width, was secured to both sides of the leg by 
a roller, for the purpose of making extension ; and in the loop 
below the foot a board was placed, wide enough to remove press- 
ure from either malleolus. To this board a cord was attached, 
and run through a hole made in the foot-board and over a pulle} T , 
and to its extremity I attached a smoothing-iron weighing about 
five pounds. Two bricks were placed under each post at the foot 
of the bed, to raise it higher than the other end, so that the body, 
constantly sliding in the opposite direction, would make a proper 
counter-extending force, without the necessity of a perineal band. 
This was all accomplished before the effects of the chloroform 
had passed off, and when she recovered her senses she said she 
felt perfectly easy. As she had already taken a large dose of 
morphine just before we arrived, nothing more was given her, 
but instructions left to administer to her twenty drops of Magen- 
die's solution in the night if necessary. 

She passed a more comfortable night than she had done for 
months, and from that time took no opiate or other anodyne. 
Her appetite improved, and her bowels became regular, without 
the use of any cathartic medicine. Iron and quinine, together with 
the most nutritious food that she could digest, were the only reme- 
dies given. A large coarse sponge, placed around the entire knee- 
joint, and secured by a very firmly-applied roller, was thoroughly 
wet in cold water, and constantly kept so by frequent irrigations 
day and night. The extension of the joint by the weight and 
pulley and the compression by the wet sponge were continued 



214 DISEASES OF THE KNEE-JOINT. 

about two months, after which I made extension by means of the 
apparatus already described, and which allows the patient to 
exercise in the open air at the same time that the extension is 
continued, which is so important in the treatment of all chronic 
inflammations of the joints. 

The instrument was applied, and when the extension was ad- 
justed she could bear almost her entire weight upon the limb ; 
but, when the bars were shortened so as to remove the extension, 
the slightest pressure upon the foot gave her the most intense 
agony. With the instrument properly adjusted, she could exercise 
in the open air upon her crutches, with the greatest freedom, and 
in perfect comfort. From this time her general health began to 
improve rapidly. After the first application she came to my 
office from Jersey City, a distance of several miles, every few 
weeks to have it readjusted, and each time showed evidences of 
most marked improvement. It was almost a year before she 
could bear much pressure without pain, when the extension was 
removed ; but, as this pain subsided, I became more free in my 
use of passive motion and in about twenty months from the 
time of the operation I had the satisfaction of seeing her walk 
without pain, and with tolerable motion of the joint. It is now 
nearly fifteen years since the case was under treatment, during 
which time she has enjoyed uninterrupted good health, and at 
the present time the motions of her knee-joint are so perfect 
that no one but a critical observer would suspect that there had 
been any disease there. 

Case. Thomas B. C, Fourth Street ; Chronic Synovitis of 
Knee- Joint / Sujopuration / Subluxation; Anchylosis; Opera- 
tion; Recovery. — This patient had scarlatina when two years 
old, following which he had chronic inflammation of the left 
knee-joint, commonly called white swelling. After about eigh- 
teen months, contraction of the muscles took place to such a 
degree as to cause subluxation of the tibia backward into the 
posterior inter-condyloid notch. Eight or nine fistulous open- 
ings around the outer part of the knee led to carious bone and 
into the joint. Drs. R. K. Hoffman and R. S. Kissam had. ex- 
amined him, and pronounced amputation the only means of 
cure. 

I was called to see him in the spring of 1853, in consultation 
with Dr. Batchelder, who advised compression by means of 



CASE. 215 

sponge, and gradual extension ; this was faithfully persisted in 
for some months, but with no appreciable improvement in the 
position of the limb. The sinuses on the outer side of the knee 
were then laid freely open — connecting with the joint — giving exit 
to a large amount of pus, and some carious bone which seemed 
to come from the external condyle of the femur and the patella 
only. The joint was freely injected with warm water, and the 
wound kept open by tents of oakum saturated with Peruvian 
balsam. Small pieces of bone continued to exfoliate for some 
months, when the wounds gradually cicatrized, and the parts 
became perfectly healthy, but with no improvement in the posi- 
tion of the limb. All the constitutional symptoms improved 
from the time the joint was freely opened ; his appetite increased, 
and his sleep was tranquil without narcotics. 

In January, 1854, as his general health had become restored, 
I decided to attempt to improve the deformity by tenotomy of 
the hamstring muscles and brisement force of the knee-joint. 
The boy was perfectly anaesthetized with chloroform, the ten- 
dons divided subcutaneously, the wounds carefully closed with 
adhesive plaster and a roller, and then the knee-joint forcibly 
broken — by flexion and extension, and internal rotation — until 
the limb was brought parallel with the other, and almost per- 
fectly straight. A tight roller was applied from the toes up to 
near the knee; a large sponge placed in the popliteal space, and 
strips of adhesive plaster were applied over the' sponge, and 
drawn tightly around the joint from the bandage below the knee, 
to some six inches above it. The roller was then continued over 
the plaster, snugly applied to the whole thigh. A piece of 
sponge about two* inches in length, and about the size of the fore- 
finger, having been placed over the track of the femoral artery — 
as is my usual custom in this operation — the roller was carefully 
applied to cause partial occlusion of the calibre of the artery, and 
thus diminish the supply of blood to the joint, without being so 
tight as to induce its complete strangulation. Two pieces of firm 
sole-leather, cut to fit the foot and limb in its entire length, hav- 
ing been softened by soaking them a few minutes in cold water, 
were applied on either side of the foot and limb, and secured by a 
bandage. Great care was taken to model the leather to all the 
inequalities of the part, while it was still soft and pliable, and the 
limb was forcibly held in its improved position until the leather 



216 DISEASES OF THE KNEE-JOINT. 

became dry and hardened, when it retained it as perfectly as any 
plaster mould could do. 1 

I wish to call especial attention to the principle involved in 
the dressing in this case, as I think it of cardinal importance, 
having witnessed its practical benefit in many serious operations. 
I mean the pressure on the main trunk of an artery leading to 
any part in danger of inflammation, in such manner as to di- 
minish the supply of blood, to prevent inflammation by partial 
starvation. Great caution is, of course, necessary not to produce 
gangrene ; but a little practice, and close observation, will soon 
give the necessary tact of knowing how to use pressure, without 
abusing it. 

In this case of young C, although the operation was very 
severe, and the force required to break up the adhesions very 
great, and continued for some time with rather rough manipula- 
tion in order to get the limb in good position, yet it was not 
followed by any constitutional excitement or irritative fever. 

The boy took an anodyne the first night only, and from that 
time had no pain or trouble whatever. The limb was kept im- 
movable in the leather splint, and was not disturbed in any manner 
for thirteen days. At the expiration of that time it was dressed 
and found perfectly satisfactory, the wounds all healed, with no 
inflammation about the joint. Our object being to obtain anchy- 
losis, the limb was again redressed, but without the sponge over 
the femoral artery. At the end of two weeks, on again examining 
it, it looked so favorably that I determined to produce a movable 
joint, instead of anchylosis. Passive motion was tried, with great 
care at first, but afterward continued with much more freedom, 
and finally resulted in a very useful joint, having about two-thirds 
the motion of a natural one. 

The patella is very small — not more than one-third the size of 
the opposite one, the external condyle of the femur is very much 
reduced, there is paralysis of the peroneal muscles, from slough- 
ing of the peroneal nerve, the foot is smaller, and the leg one inch 
shorter than the other. Yet, with a high heel, an elastic spring 
on the outside of the shoe, and an India-rubber substitute for the 

1 Subsequent experience has taught me that it is better to close the wounds and 
retain the limb at perfect rest in its abnormal position until the external wounds have 
healed (which will generally be done in five or six days), before proceeding to break 
up the bony adhesions. 



CASE. 



217 



peroneal muscles — running from the top of the fibula to the ankle, 
where it terminates in a catgut cord, which plays around a pulley, 
and is inserted at the outer margin of the sole of the boot near 
the toe — the boy walks, dances, runs, and skates with his play- 
mates without crutch or cane. 

Case. Chronic Inflammation of the Knee- Joint with Sub- 
luxation. — March 4, 1873. — James M., of Williamsburgh, car- 
penter, aged fifty-two, very strong and robust ; four years since, 
while lifting a heavy weight, he stepped on a stone and slipped, 
" something cracked in his right knee like a pistol." The knee 
swelled very much ; did not lay him up ; continued work all the 
time for two years, although the knee was swollen to nearly twice 
the size of the other. He was then thrown from a wagon, strik- 
ing upon the outside of the lame knee, and was laid up with an 
acute inflammation of the joint. Six months after this a gather- 
ing took place, and opened on the inner side of the popliteal 
space, discharging very freely for two or three months. The 
opening still discharges a small amount of glairy fluid. The 
probe passes five and a half inches around the joint, but I do not 
touch bone. 

Present condition seen in Fig. 141, with comparative measure- 
ments of the two limbs. 




RIGHT. 15 "Iz h 16 /nches, 
LEFT, 13 IS wfz Inches. 



Fig. 141. 



Diagnosis. — Chronic inflammation of the knee-joint, with 
subluxation. 

Treatment. — Extension in two directions, as seen in Fig. 130, 
after which the knee is to be compressed with wet sponge and 
roller. May possibly require exsection. 



218 DISEASES OF THE KNEE-JOINT. 

April 10th. — Measurements decreased from IT to 16^ about 
the knee ; below the knee 15f to 14£ ; above knee not changed. 
Position straightened to dotted line in Fig. 141 ; knee-extension 
splint applied. 

May 16th. — Readjusted rollers. The plasters, which have 
been on one month, are in good condition, and the instrument 
was properly extended ; could bear almost his entire weight on 
limb without pain. Limb perfectly straight ; discharge from it 
very slight ; improved in every way. 

June 16th. — Readjusted plasters for the first time ; much im- 
proved. 

May 7, 1874. — Plasters removed for the fourth time, and the 
joint is perfectly cured. The limb is straight, and can sustain 
entire weight of body. Has moderate motion. Removed all 
dressings, and applied roller-bandage; advise frictions and elec- 
tricity, with passive motions. 

July 1, 1874. — Patient walked to the office from Williams- 
burgh ; is in perfect health ; no pain whatever about the knee- 
joint ; can extend leg perfectly straight, and flex it to nearly a 
right angle. Flexion may, possibly, be increased in time. 

Yery many of the cases, however, which you will be called 
upon to treat, will be those which have been neglected, and in 
consequence the disease has become far advanced. 

You may, then, see a joint in which there is extensive destruc- 
tion of the soft parts, extensive disease of the bony structures, 
accompanied by exhausting discharges, and very grave constitu- 
tional disturbance. 

In such cases, if there is reasonable hope of being able to 
relieve the patient of this source of constitutional exhaustion and 
disturbance, by removing the dead bone, and establishing free 
drainage from the bottom of all sinuous tracts, an operation may 
be made for that purpose. If deemed justifiable, make, a large 
opening in the soft parts so as to establish perfect drainage and 
prevent any collections of pus; then drill, gouge, and chisel, until 
all dead bone is removed ; draw setons of oakum or perforated 
India-rubber tubing through the joint to avoid the possibility of 
the retention of pus, place the limb upon an extending and coun- 
ter-extending apparatus, and carefully watch the progress of the 
case. 

If this progress is favorable, both locally and constitutionally, 



EXSECTION. 219 

it will be good evidence that your operative interference has been 
in the right direction. If, however, the changes are unfavorable, 
you may next resort to exsection of the joint. 

In those cases which have become so far advanced as to admit 
of no delay,- exsection or amputation may be resorted to at once. 

There are cases also in which the disease steadily progresses 
toward an unfavorable termination, even when the very best 
plan of treatment is adopted and carried out in the most faithful 
manner. Such cases will probably require exsection or amputa- 
tion ; therefore we will study the subject of exsection at our next 
lecture. 



LECTUKE XYIII. 

DISEASE OF THE JOINTS. KNEE-JOLNT (CONCLUDED). EXSECTION. 

Mode of performing the Operation of Exsection. — Splints and Dressings used after the 
Operation. — Partial Exsection. — " Bryant on the Least Sacrifice of Parts as a 
Principle in Operative Surgery." — Differential Diagnosis. — Bursitis. — Necrosis of 
the Lower Extremity of the Femur. 

Gentlemen : You will recollect I stated at my last lecture 
that there are certain cases of chronic disease of the knee-joint in 
which the operation of exsection will be demanded, and it is to 
the consideration of this subject that I shall first direct your at- 
tention this morning. 

Exsection of the knee-joint should be performed in the follow- 
ing manner : 

Make a single U-shaped incision, beginning at the posterior 
portion of the inner condyle of the femur, passing downward and 
across a little below the lower border of the patella, and thence 
back to the posterior portion of the external condyle of the femur. 
I prefer the incision made in this manner to the H -incision, for 
the reason that it is equally serviceable, and exposes a much less 
extensive surface of bone. Turn the flap back and remove the 
patella whether it is diseased or not. By some it is recommended 
to peel the patella out from the periosteum, but removing a 
healthy patella in that manner is impossible. 



220 DISEASES OF THE KNEE-JOINT. 

Having removed the patella, you will next loosen the attach- 
ments of the ligaments as little as possible, just sufficient to per- 
mit section of the bones with the saw. 

The next step in the operation is to remove a segment of 
bone from the lower portion of the femur and upper portion of 
the tibia, in such a manner as will permit restoration of the limb 
to the straight position in which you wish the anchylosis to take 
place. 

To perform this part of the operation properly, requires con- 
siderable skill, and you may not succeed at the first trial in mak- 
ing your sections at such angles as will allow you to place the 
limb in the proper position after the pieces of bone have been 
removed. To this end, you have simply to recollect that your 
saw must pass through the femur and tibia, parallel with the articu- 
lar surface of each bone, and not at right angles to the shafts of the 
bones. The bones should not be laid bare to an extent greater 
than is absolutely necessary to fairly expose the portion to be 
removed. 

Section of the bone must be sufficiently extensive to remove 
all necrosed and carious portions ; consequently you will continue 
removing bone, if your first section is not sufficient, until you 
arrive at a point where a fresh bleeding surface is obtained, in- 
dicating healthy bone. 

The next step in the operation is to bring the fresh surfaces 
of the bone into perfect coaptation, and then retain them in that 
position with silver-wire sutures. 

After the bones have been properly secured, you will fix the 
limb in some apparatus which will give absolute rest. For this 
purpose the splint of Dr. John F. Packard, of Philadelphia, is 
one of the best that can be employed, and which is described by 
him as follows : 

" In order to get a perfectly accurate measurement, I trace an 
outline of the limb upon a sheet of coarse strong paper placed 
beneath it. Should the knee be very much flexed, the outline 
of the thigh may be made first and then that of the leg, mark- 
ing the limb and paper so that the two proportions may exactly 
correspond. This pattern should extend on the outer side up to 
the greater trochanter, on the inner, up to the perinseum, and 
about four inches beyond the heel. A curved line should be 
drawn corresponding to that of the buttock for right or left side. 



PACKARD'S KNEE-SPLINT. 



221 



The figure so described inay be cut out and made the pattern for 
the splint, which should be made of inch-board (although thinner 
stuff will do for smaller limbs). Above, at the buttock end, this 
board is beveled off so that no edge shall irritate the shin, and a 
hollow is made near the lower end to receive the heel ; the whole 
is slightly hollowed from side to side so as to make a very shallow 
trough. 

" A slit is mortised lengthwise in the middle line, close to the 
lower end of the splint, to receive the tenon of the foot-piece. 
This latter should be slightly inclined and long enough to extend 
up above the toes so as to keep the weight of the bedclothes off 
the foot. It may be fastened securely at any desired point by 
means of a wooden pin or wedge. {See Fig. 142.) 

• A piece corresponding to the knee is now sawed out, the saw 
lines being made to converge slightly from without inward so 
that the piece shall be a little wider on the outer side, making it 
slide out and in more easily. The saw may be carried so as to 
cut the edges of the knee-piece, as seen in the diagram ; or, if a 
carpenter be employed, a regular groove may be cut in the thigh 
and leg pieces, with a corresponding ledge on the knee-piece. 

Two strong metal brackets of suitable size are screwed on to 
the thigh-piece above and the leg-piece below so as to connect 




Fig. 142. — From above. 




Fig. 143. — From the Side (the Slide removed). 

them firmly. These brackets should be from six to nine inches 
high, and should be flared somewhat outward ; just at their point 
of attachment they should curve sharply outward, as seen in Fig. 



222 DISEASES OF THE KNEE-JOINT. ■ 

143, so as to prevent any pressure against the limb in case the 
latter should swell. 

" Side-pieces of soft leather are next tacked on the upper sur- 
face near the edge of each portion of the splint ; they may be 
made to fasten by laces, or, if preferred, by straps and buckles. 

" The limb being laid on this splint, previously padded, is per- 
fectly secure. Sometimes it is well to add a small strip of paste- 
board on the upper surface of the thigh and another for the leg. 

" To change the dressings it is only necessary to undo the 
leathers, and to draw out the middle shelf, holding the dressings at 
the inner side lest they should have become adherent. The knee 
is thus left exposed, and, when the dressings have been changed, 
the shelf is slipped in again and fastened as before. I have some- 
times had a small catch put on at the outer edge, but do not 
think it necessary. Before using the splint it is well to have the 
knee-piece, and the adjoining portions of the thigh and leg 
pieces, thoroughly oiled so that they may be less apt to absorb 
any discharges which may flow down over them." 

You will doubtless get into trouble in attempting to use such 
complicated apparatus, unless you are thoroughly familiar with 
its mode of application ; but, if you will keep the principle in 
mind, namely, absolute rest with the limb in the proper position, 
it will soon be seen that a great variety of mechanical appliances 
can be devised to put it into practical operation. 

The plaster-of -Paris dressing is one that can be easily applied, 
and is both cheap and efficient. It consists in the application 
of strips of flannel, saturated with plaster of Paris, along the pos- 
terior surface of the thigh and leg, and along the sole of the foot, 
and of sufficient width to half encircle the limb. In this way a 
strong and immovable splint can be easily made. The plaster 
hardens very quickly, and when hardened the limb can be addi- 
tionally secured to the splint by means of a roller bandage. The 
entire secret of success in exsection of the knee-joint is, first to 
make your incision through the soft parts in such a manner that 
the outer angle will be as low as the lowest portion of the inci- 
sion through the bone ; and, second, to secure absolute rest for the 
parts after the operation has been performed. It is important to 
extend the incision through the soft parts as far back toward the 
posterior, aspect of the limb as the incision through the bone 
extends, in order to give perfect drainage. All that is necessary, 



PARTIAL EXSECTION. 223 

when these indications are fully met, is to retain the limb in the 
condition of absolute rest until perfect consolidation has taken 
place. 

Exsection at the knee-joint is attended with considerable 
danger, and in man}^ instances you may justly hesitate before 
resorting to the operation. 

If the disease of the joint is not sufficiently extensive to war- 
rant complete exsection, you may remove all the dead bone, by 
drilling and gouging ; pass setons of oakum or perforated rubber 
tubing through the joint for the purpose of securing complete 
drainage, and conduct the treatment upon the general plan rec- 
ommended when speaking of the management of the ankle-joint. 

Exsection can be performed much more quickly than the op- 
eration just indicated ; but, when the disease does not involve the 
entire joint, when the risk is considerable, or when the sur- 
rounding conditions are unfavorable, exsection should be avoided. 
In such cases I rely chiefly npon the operation for partial removal 
of the joint and the result in many cases is very satisfactory, as 
you have already seen at our clinics. 1 

This plan of treatment, which I have practised for more than 
twenty years, I am happy to say is now being adopted, in Eng- 
land. Mr. Bryant, the distinguished surgeon of Guy's Hospital, in 
his recent papers published in the London Lancet, " On the Least 
Sacrifice of Parts as a Principle in Operative Surgery," has this 
remarkable statement : 

" I trust that this series of cases is enough to demonstrate with sufficient 
clearness the value of the practice I am now inculcating, and to show that in 
a large number of cases of disease of the joints a cure may be secured by a 
simple incision into the affected joint and the removal of necrosed bone. The 
series includes examples of disease of the shoulder and elbow, hip, knee, 
ankle, and great-toe joints, and I do not think I should be far wrong if I 
were to express my belief that in many of the cases, if not in all, many sur- 
geons—more particularly those who are advocates for excision — would have 
excised the joints, and some few would have amputated. I am not here, 
however, to condemn their practice, for their results might have been good ; 
but, whatever they might have been, they would have been secured by severe 
operative measures, and consequently by dangerous risks, whereas in the 
treatment I am now advocating the surgical proceedings are simple and are 
attended with a minimum of danger. The success of the practice I have 
recorded was also great." 

1 See case Thomas B. C, Lecture XVII. 



221 DISEASES OF THE KNEE-JOINT. 

During the remainder of the hour we will study some of the 
diseases that may be mistaken for chronic disease of the knee-joint. 

Bursitis.— The bursee about this joint sometimes become the 
seat of inflammation, which goes on to suppuration and the for- 
mation of large abscesses. 

When such a case presents itself, if of long standing, there 
will probably be numerous openings above and below the joint, 
and many of them will connect with each other through long, 
tortuous sinuses, that lead off into pockets here and there filled 
with pus. These sinuses and pockets are always lined with a 
thick membrane, which keeps up a constant secretion. The long- 
continued and exhausting discharge gives rise to more or less 
constitutional disturbance, and the swollen and infiltrated con- 
dition of all the tissues about the joint imparts to it an appear- 
ance and feel very much like that seen in true disease of the 
joint itself. 

When, however, these sinuses are explored with my verte- 
brated flexible probe {see Fig. 144), or the elastic flexible probe 
of Mr. Charles Steele, F. E. C. S., of Meridan Place, Clifton, 
Bristol, England {see Fig. 145), you will find that they have been 



.^ 



Fig. 144. 




Fig. 145. 



made by pus burrowing in the cellular tissue beneath the skin 
and among the muscles, and are all extra-capsular. The charac- 
teristic appearance of the external openings when dead bone is 
present is not seen in these cases. This probe of Mr. Steele's, 
although apparently such an insignificant instrument, is yet one 
of the greatest value, and I think an improvement upon my own. 
The most certain method of recognizing the difficulty, how- 
ever, is to make a thorough examination by crowding the bones 
together, by extension, and by pressure over the insertion of the 
coronary ligaments, for in this way you will be able to determine 



NECEOSIS OF THE FEMUK. 225 

whether the joint is involved or not, When this is done it will 
be found that scarcely any symptoms are present indicative of 
true disease within the joint. 

It is very difficult in certain cases to determine whether the 
fluctuation that may be present is within the bursa over the joint, 
or is due to the presence of fluid in the joint itself. If the bursa 
alone is involved, the patella will be crowded firmly against the 
condyles of the femur; whereas, if the effusion is within the 
joint, the patella will be lifted from the condyles, and can be 
pressed against them in many instances so as to produce an audi- 
ble click. 

The treatment for cases of bursitis of long standing is to 
open all the sinuses freely, remove the lining membrane, and fill 
the cavities with oakum saturated with Peruvian balsam. In 
this manner you will be able to establish the healing process at 
the bottom of the cavities lined with pyogenic membrane, and 
the case will probably give you no further trouble. 

Necrosis of the Lower Extremity of the Femur. — Necrosis of 
the femur at its lower extremity is quite commonly mistaken for 
chronic disease of the knee-joint. {See Case, page 409.) 

In occasional cases it is very difficult to make a correct diag- 
nosis. The most common seat of the necrosis is along the course 
of the branches of the linea aspera, including the popliteal space 
of the femur. These bifurcations have edges more or less rough 
and cutting, which will break through the periosteum when it is 
firmly pressed against them. For instance, a person may fall 
from some height, and in the descent his leg may become caught 
in such a manner as to make severe pressure just over the peri- 
osteum covering these ridges, perhaps sufficient to wound the 
periosteum without making any external wound. Such an injury 
may give rise to periostitis and subsequent necrosis of the bone. 
When such results follow an injury of this character, it takes a 
long time for the difficulty to make itself manifest upon the 
thigh, on account of the depth of the disease beneath the surface. 
But the damage done, and necrosis following, pus is retained and 
burrows among the tissues, and the disease is so near the knee- 
joint that it is very liable to be mistaken for true joint-disease. 

All that is necessary to do in these cases, to arrive at a correct 
diagnosis, is to make a thorough examination of the joint in the 
manner already described. If your examination is thorough, and 
15 



226 DISEASES OF THE KNEE-JOINT. 

disease of the joint is present, you will be able to detect it. You 
will also observe that there is no abduction or twisting of the leg 
outward, as shown to result when the joint has been long in- 
volved ; but, on the contrary, the leg will be found flexed in a 
straight line with the femur, and has no outward rotation. The 
external openings of sinuses communicating with dead bone have 
such a characteristic appearance, described by the late Dr. Alex- 
ander Stevens as resembling the anus of the hen, as to be abso- 
lutely unmistakable. When this is present, therefore, you will 
at once use a flexible probe {see Figs. 144: and 145), which will 
follow the lead of any opening under the fascia or elsewhere, and 
finally conduct you to the dead bone, and then your diagnosis is 
positive. 

In some cases, however, which have fallen under my observa- 
tion, there were no openings until I had made one for the pur- 
pose of exploration. Such an incision can be made through the 
vastus externus muscle, when the bone is very readily reached 
without incurring any risk from haemorrhage. 

The incision will probably give free discharge to pus ; and 
then, with your finger or probe, the exploration can be continued 
until the diagnosis is completed. In some cases, perhaps, the parts 
can be saved by making a free incision through the periosteum 
before death of the bone takes place. When diseased bone is 
found, proper measures can be resorted to for its removal. If 
you are not able to remove all the dead bone at the time of the 
first operation, draw a seton of oakum or an India-rubber tube 
through the wound, and leave Nature to remove the remaining 
portion. 

An important point with regard to operations for the removal 
of dead bone in this region, as well as elsewhere, is to preserve 
the periosteum as much as possible. 

The permanent deformity which commonly follows chronic 
disease of the knee-joint is anchylosis with distortion. The sub- 
ject of anchylosis will be fully considered hereafter. 



ANATOMY OF THE HIP- JOINT. 227 

LECTUKE XIX. 

DISEASES OF THE JOINTS. MOEBTTS COXAEIUS. 

Anatomy of the Hip-Joint. — Pathology of Hip-Disease. — Etiology. — Symptoms of 

First Stage. 

Gentlemen : We shall next consider that malady which occu- 
pies the chief place among affections of the joints, namely, Mor- 
bus Coxarius, or hip-disease. But, before entering upon the 
consideration of the symptoms and morbid changes of structure 
in this disease, it will be necessary for me to give a brief descrip- 
tion of the most important anatomical structures entering into 
the composition of the hip-joint, in order that you may fully 
comprehend the principles which I shall endeavor to establish as 
the proper basis for correct treatment. 

Anatomy of the Hrp-JonsrT. — The osseous structure of the 
hip- joint is made up of the os innominatum and head of the os 
femoris, the latter being received into a deep cavity of the 
former, the acetabulum, by a kind of articulation called enar- 
throdial, or ball-and-socket joint. 

The head of the femur and the acetabulum are cancellous in 
structure ; quite vascular, and subject to inflammation. 

The acetabulum is lined with cartilage at all parts, except at 
a circular pit (fundus acetabuli), which occupies the lower part 
of the cavity near the notch, and is cushioned with fat. The 
head of the femur, which fits into and articulates with the ace- 
tabulum, is nearly two-thirds of the segment of a sphere, and is 
entirely covered with cartilage, except at the deep pit, which is 
for the insertion of the ligamentum teres, at its upper and inner 
face looking toward the cavity of the pelvis. 

The proper ligaments of the hip-joint are the capsular, the 
ileo-femoral, the ligamentum teres, the cotyloid, and the trans- 
verse. 

The Capsular Ligament (A, Fig. 146) is the largest and 
strongest capsule in the body. It is attached above to the outer 
border of the acetabulum and outer face of the cotyloid ligament ; 
and below, to the anterior inter-trochanteric line, and neck of the 
femur, which latter it completely surrounds. It is thicker and 



228 



DISEASES OF THE HIP-JOINT. 



longer in front than behind, and it is more extensively attached 
at* its upper part, where strength and security are required. The 
strength of the capsular ligament is further greatly increased by 
the ileo-femoral ligament (B, Fig. 146) which is accessory to it, 
and extends from the anterior inferior spinous process of the 
ilium to the anterior intertrochanteric line. This ligament has 
been called the Y-ligament by Dr. Bigelow, of Boston. 





Fig 146. 



Fig. 147. 



The Cotyloid Ligament (C, Fig. 147) is a thick prismatic 
ring of fibro-cartilage, mounting and attached to the brim of the 
acetabulum by which the cavity is deepened. 

The Ligamentum Teres (A, B, Fig. 147) is attached by a 
round apex to a pit just below the middle of the head of the 
femur ; it divides into two fasciculi, which are inserted into the 
corners of the notch of the acetabulum A, B, and the cotyloid 
ligament, and is covered by synovial membrane. 

The Transverse Ligament is continuous with the cotyloid, 
extending from one point of the notch to the other, and com- 
pleting the circle of the cotyloid ligament, thus converting the 
notch of the acetabulum into a foramen, through which the blood- 
vessels enter to supply the interior of the joint. 

The synovial membrane is quite extensive, lining the capsular 
ligament, the free surface of the cotyloid and transverse liga- 
ments and the ligamentum teres, as far as the head of the bone. 



PATHOLOGY. 229 

We are now ready to pass to the study of the pathology of 
this disease. 

Pathology. — Under this head we shall describe the changes 
that take place in the tissues of the joint at the very beginning 
of the disease, leaving those which are present in the more ad- 
vanced conditions to be considered in connection with the symp- 
toms to which they give rise. 

1. The disease may begin as a synovitis. 

2. It may begin in a rupture, partial or complete, of the liga- 
mentum teres ; thereby interfering with the nutrition of the head 
of the femur. 

3. It may begin from rupture of some of the minute blood- 
vessels which are situated in the bone just beneath the cartilage of 
incrustation. This may occur either upon the head of the femur 
or at some point in the acetabulum, and results from blows, 
jumping, or anything which may produce a sudden concussion of 
these articular surfaces. These three conditions require special 
consideration : 

1. Of synovitis. Inflammation of the synovial membrane of 
the hip-joint may be produced in the' same manner as it is pro- 
duced in any other joint of the body, but it is almost always the 
result of exposure to sudden changes of temperature after violent 
exercise, such as skating, racing, jumping, playing at foot-ball and 
other movements that over-exercise the joint. 

When the synovial membrane becomes inflamed, effusion of 
fluid into the cavity of the joint always takes place. The syno- 
vitis may be subacute in character, and attended by the effusion 
of only a small quantity of fluid, but not followed by disintegra- 
tion of the tissues of the joint ; or the same degree of inflamma- 
tion, in some cases, may be followed by complete disintegration 
of the joint structures. 

Again, the synovitis may be very violent, accompanied by 
intense pain and the effusion of a large quantity of fluid, and 
make rapid progress toward destructive changes within the joint. 
When the joint becomes distended with fluid there will be pres- 
ent a peculiar deformity, which we shall fully describe when we 
come to study the symptoms of the disease in its second stage. 
Of course the synovial membrane sooner or later becomes in- 
volved, as do the cartilages, ligaments, and bones, no matter how 
the disease begins ; but that there are cases of hip-joint disease 



230 DISEASES OF THE HIP-JOINT. 

which have their commencement in a synovitis I am fully con- 
vinced. 

2. Any violent straining of the ligamentum teres, such as may 
be caused by forcibly stretching the legs apart, or by other violent 
exercise which gives motion to the joint to the extreme limits, 
may partially or completely separate it from any of its attach- 
ments to the bones. It is most likely, however, to be separated 
from its attachments to the head of the femur. When such an ac- 
cident occurs the vessels which supply the head of the femur are 
destroyed, and necrosis follows as the result of interference with 
its nutrition. Secondary changes soon occur in the cartilages and 
the synovial membrane, and the case goes on, if not relieved, to 
the development of the disease in its worst form. 

3. When the disease begins in the blood-vessels in the artic- 
ular lamella, it first appears as an extravasation or " blood-blister " 
at some point. This is the nidus, or starting-point, and, if the 
damage done is detected at the time of the infliction of the in- 
jury, rest, alone, if continued for a sufficient length of time, will 
probably bring about a favorable termination in a great majority 
of instances. But the damage done not being detected, and in 
many instances not even suspected, the rest necessary is not insisted 
upon at the proper time ; consequently the disease is slowly devel- 
oped, and frequently is not distinctly pronounced until long after 
the accident that has caused the trifling damage to the blood-ves- 
sels, and given rise to so much trouble, has been entirely forgotten. 

A pinch of the skin producing a "blood- blister," or slight 
extravasation of blood within the cellular tissue, is of common 
occurrence, and is of no great importance. If let alone, it will 
soon be absorbed ; or at most, if you let the fluid out and do not 
irritate the wound, it will soon get well. But suppose, even in 
this most trifling injury, that, instead of giving it rest and time to 
heal, you constantly scratch it with a rusty nail ; you will produce 
a sore that will last as long as the irritation is continued. This is 
a parallel case with a joint that is exercised after concussion, or a 
blow or wrench that has produced an extravasation of blood from 
the tufts of blood-vessels already referred to. 

Now, while I believe that this disease begins in one of the 
three ways mentioned, I would have you understand that the dis- 
ease does not progress very far, without involving all the struct- 
ures entering into the composition of the joint. 



ETIOLOGY. 231 

For instance, when the disease begins as a synovitis, the carti- 
lages, bones, and ligaments, sooner or later become involved. So, 
when the disease begins in destruction of the ligamentum teres, 
partial or complete, the same consequences ensue, and the same is 
true when the disease begins as an extravasation of blood in the 
manner described. 

I do not believe, however, that the disease ever begins in the 
cartilages of the joint, for the reason that these structures contain 
neither blood-vessels nor nerves. Necrosis occurs secondarily in 
the cartilages on account of the loss of nervous and vascular sup- 
ply to the tissues upon which they depend for nutrition. 

This, according to my view, constitutes the pathology of this 
disease at its very beginning. There are other and very impor- 
tant pathological changes that occur as the disease progresses; 
but, inasmuch as certain symptoms, such as certain positions which 
the limb assumes, are directly dependent upon such pathological 
changes, I shall consider them in connection with the symptoms 
to which they give rise. We now pass to the subject of etiology. 

Etiolog-y. — Almost all surgical authorities agree that morbus 
coxarius is invariably the result of a contaminated constitution ; 
in other words, that it is essentially strumous in its origin. This 
has been the universal opinion, and the doctrine has descended 
from teacher to student, and is still extant among the majority of 
surgical practitioners. It has been so often taught and enforced 
by frequent repetitions, that nobody considered it worth while to 
question its truth ; but nearly all have taken it for granted that 
an assertion so positively made and universally accepted must be 
based upon mature investigation. When I first entered the pro- 
fession I accepted this doctrine taught by our fathers, but must 
confess that I never was fully satisfied with regard to its correct- 
ness. Now, while I revere the labors of those great men in the 
advancement of scientific investigation, I must be permitted to 
question what is questionable, and to doubt what is doubtful. 

Examination of the cases which have presented themselves to 
my notice since that time has convinced me that the cachectic 
condition so often seen is the result and not the cause of the dis- 
ease ; for very many of the patients in the earlier stages of the 
disease have possessed all the appearances of robust health, and, in 
all those cases in which the disease has been cured by Nature's 
method, the patient, subsequent to the cure, has been hale and 



232 DISEASES OF THE HIP-JOINT. 

hearty. I do not suppose there is a person in this room who 
cannot call to mind some old fellow with a shortened hip, per- 
fectly anchylosed, who yet has a ruddy face, a good healthy com- 
plexion, and is a vigorous, robust old man. If he had had scrofula 
in his system, it would have remained there, and when his hip 
had recovered the man would have been a miserable old fellow 
after all. The very fact of his becoming a vigorous, robust man 
after going through all the exhausting effects of hip-joint disease 
proves, in my judgment, that the disease is not of constitutional 
origin. 

The additional fact that, in so many cases, the joint has been 
exsected when the patients have been, apparently, at the point of 
death, and after the removal of the dead bone have become vigor- 
ous, strong persons, is good evidence that the disease is not con- 
stitutional. Then there is the still stronger fact that, by treating 
the disease locally without reference to constitutional taint, we 
obtain perfect results, so much so that the patients recover with 
perfect motion and without the slightest deformity, which is the 
best proof in the world that the disease is essentially local in 
character. 

Another fact worthy of consideration is that a very large pro- 
portion of cases of the disease occur in children, while the scrofu- 
lous condition is by no means so restricted. 

I have unfortunately recorded only a small part of the cases 
which have fallen under my observation, but three hundred and 
sixty-five cases have been fully entered upon my record, and, of 
these, two hundred and twenty-one were under the age of fifteen 
years, and one hundred and twenty-one were under the age of 
five years. Similar results have been obtained by other gentle- 
men who have collected statistics upon this point. 

Now, it is not necessary for me to prove that adults are nearly 
as liable to be affected with scrofulous diseases as are children, 
the less number of cases seen being due mainly to the fact that 
these sickly children are very liable to die before reaching adult 
life. If, therefore, we still adhere to the scrofulous theory, we 
are forced to conclude that the diathesis, w T hich in childhood 
develops itself in joint-disease, manifests itself in some other way 
after puberty. This I cannot believe. Childhood is the age of 
restless activity, and, out of the hundreds of cases in which I have 
taken the trouble to trace their history, I have found that the 



CAUSES. 233 

immense majority, I may safely say seventy-five per cent., have oc- 
curred in the most vigorous, robust, wild, harum-scarum children — 
those who take their chances of danger, who run races, climb over 
fences, jump out of apple-trees, kick their playmates down-stairs, 
ride down balusters, and are generally careless and reckless. 

On the other hand, the adult does not place himself in the 
position in which he can receive so many blows or falls as the 
active child does, and furthermore he immediately notices the 
effects of his injury, and takes precaution against its development 
into serious trouble. The child, however, knows nothing of re- 
sults, and, unless the pain from the injury is great, will probably 
fail to complain of it, and soon forget it altogether. This, I 
believe, is the true reason why so many more cases of joint-disease 
are seen in children than in adults. 

I do not wish to be understood as saying that scrofula is a 
preventive of disease of the hip-joint, as has been asserted concern- 
ing my teaching. All things considered, a smaller amount of 
injury will produce the disease in one of these miserable, sickly 
children, than in a healthy, robust child. But the sickly, scrofu- 
lous child, who clings to his mother's apron, does not run the risk 
of getting hurt as do these active, restless children ; consequently, 
the majority of cases occur among the active and robust. 

From what has been said, you have probably already drawn 
the inference that I regard the disease as one almost invariably 
due to a traumatic cause, and not dependent upon some con- 
stitutional taint. To what has already been said upon this point, 
we may add the positive evidence of statistics. 

Of the three hundred and sixty-five cases alluded to above, 
traumatic cause was assigned by the patient or the parent in two 
hundred and fifty-seven, while in one hundred and eight cases 
the cause was recorded as unknown. 

In two hundred and seventy-eight cases, the previous general 
condition of the patient was good ; in forty-two cases it was bad ; 
and in forty-five cases it was unknown. These figures are taken 
from the notes of my own fully -recorded cases. Cases not fully 
recorded have been rejected in making these statistics. 

Now, the cases in which the previous condition was bad, to- 
gether with those in which it was unrecorded, make up less than 
twenty-four per cent, of the whole ; and it is possible that very 
many of those had a traumatic origin that had been overlooked 



234 DISEASES OF THE HIP-JOINT. 

or forgotten, owing to the insidious manner in which the changes 
had come on. 

My own clinical observations with reference to this point 
stand by no means isolated. The same observations have been 
made by other surgeons, both in this country and Europe. 

It generally requires a very close examination to find out the 
cause, since the disease does not usually immediately follow the 
injury, but often first manifests itself weeks, and even months, 
after the accident that has given rise to it has occurred ; so that 
the patient and his friends naturally enough forget the accident 
and its connection with the disease, until especially reminded of 
it in the investigation. 

So much, gentlemen, for the pathology and causation of hip- 
joint disease, and now we are ready to begin the study of its 
symptoms. 

Symptoms. — These will vary according to the stage in which 
the disease presents itself. 

Ordinarily three stages are described : 

1. The stage of irritation or of limited motion, before the 
occurrence of effusion. 

2. The stage of " apparent lengthening," or of effusion, the 
capsule of the joint remaining entire. 

3. The stage of if shortening," or of ruptured capsule. 

For the second and third stages, I prefer to use the terms 
effusion and rupture, rather than " apparent lengthening " and 
" shortening," as the latter describe only a single feature of the 
deformity present in each stage, while the former designate an 
essential pathological change which underlies a group of symp- 
toms. What, then, are the symptoms of thejlrst stage f 

The symptoms of this stage are sometimes exceedingly ob- 
scure, particularly if the inflammation be of a low grade, or of the 
chronic character generally found in those of a strumous diathesis. 
The first thing that attracts the attention of the patient or his 
friends is generally a stiffness about the joint and a limping gait, 
for which, perhaps, they will be unable to assign a cause. The 
real cause (commonly traumatic) has been forgotten in conse- 
quence of the slow and insidious approach of the disease. This 
stiffness of the joint is commonly noticed first in the morning 
when the patient gets up. After he has been about for a while 
he becomes limbered up, and can travel without stiffness or ap- 



SYMPTOMS IN FIRST STAGE. 235 

preciable limp. But, even then, when he stops walking or run- 
. ning he will, within a minute or two, invariably stand upon the 
sound leg, apparently for the purpose of relieving the affected 
one. 

[Now, even at this early stage of the disease, if the patient be 
taken to the surgeon, a careful examination will reveal the fol- 
lowing condition of things: 

It is to be noticed, however, that no deformity of which you 
are certain can be detected at this stage unless the patient is com- 
pletely stripped of clothing from the waist down, and then placed 
in a proper position. 

When the patient has been stripped, place him first in the 
standing position, and directly in front of you with his back tow- 
ard you. 

The light should fall directly upon his back, in order that you 
may not be deceived with regard to details of contour by any 
shadows. Your examination should not be hurried, for you wish 
to detect the disease in its very incipiency, in its most shadowy 
form. After watching the patient a short time you will notice 
that he makes a solid column of the sound leg for the purpose of 
receiving concussion and bearing the weight of the body, and also 
carefully avoids all concussion of the suspected limb. You will 
further notice that the suspected limb has a tendency to slight 
abduction and slight flexion at the knee and hip, but the feet 
stand parallel with each other. The natis upon the side of the 
lameness drops a trifle, is somewhat flattened, and the gluteo- 
femoral crease is lower and shallower than upon the healthy side. 
{See Fig. 148.) 

This dropping of the natis is due to relaxation and gravitation 
of the gluteal muscles while the weight of the body is thrown 
upon the sound leg ; for the same thing occurs if the knee-joint 
be affected, or a perfectly sound person throws his weight upon 
one leg. 

This symptom, then, has a diagnostic value only so far as this 
— it indicates to us that from some cause the patient rests the 
weight of the body chiefly or entirely upon one limb. But from 
this peculiar favoring of the affected side we can often detect the 
incipient disease, even before a limp has been noticed. JSText you 
will determine whether there is present any rigidity of the psoas 
magnus, iliacus internus, or adductor muscles of the thigh ; for 



236 



DISEASES OF THE HIP-JOINT. 



rigidity of these muscles appears very early in the disease, and, 
if none of them give resistance to the full performance of their 
normal functions, it is fair to assume that the joint is not dis- 
eased. 

To make an examination for this purpose it is necessary to 
lay the patient upon his back upon a firm, flat surface like a table 




Fig. 148. 



or floor. This examination must be made upon a solid, flat sur- 
face. A bed, or sofa, or lounge, therefore, will not answer; for 
the inequalities of either will adapt themselves to the curvatures 
of the spine, thereby preventing you from detecting the deformity 
of this early period of the disease. 

Before proceeding further it is necessary to place the patient 
in such a position as will furnish a proper starting-point from 
which you may conduct your examination. Such a position is 
one in which the pelvis and trunk are at right angles with each 
other, and is obtained in the following manner : Lay the patient 
on his back upon a table, or some solid surface, covered only with a 
blanket, in such a manner that his entire spine will be brought 
upon the plane. This can be done by placing your arm under 



EXAMINATION IN FIRST STAGE. 



237 



the knees and lifting the thighs, or by lifting them in any other 
way, until the spinous processes of the vertebrae have touched 
the solid plane upon which the child is lying (see Fig. 149). 
Then draw a line from the centre of the sternum over the umbili- 
cus to the centre of the pubis, and cross it at a right angle by a 
line drawn from one anterior superior spinous process of the ilium 




Fig. 149. 

to the other. When this is done, and the two lines above men- 
tioned are at right angles, the spinal column is slightly straighter 
than normal, but it and the pelvis are at right angles with each 
other ; and, if no disease exists within the hip-joint, the limb can 
be brought down, so that the popliteal space can be made to 
touch the plane, without disturbing the relation of the lines 
above described, or lifting the spinous processes from the plane. 
If you, therefore, hold the suspected limb in your hand in such a 




Fig. 150. 



manner as to keep the spinous processes on the table, while the 
other lines are at a right angle, you will observe that the well 
limb can be pressed down to the table so that the popliteal space 
will touch (see Fig. 150). The diseased one can be pressed down 
to nearly this position, but, before the popliteal space touches the 
plane, you will notice that the pelvis becomes tilted, making a 
curve in the lumbar vertebrae so that the hand can be passed be- 
tween the child's back and the table (see Fig. 151). 



238 DISEASES OF THE HIP-JOINT. 

This arching of the spine in many cases at this early period in 
the disease is so slight that it would be entirely overlooked were 
the examination made upon other than a solid flat surface. 

Complete flexion at this period of the disease is also impos- 
sible. The well limb can be flexed so as to bring the knee in con- 
tact with the chest ; but the diseased limb can probably be flexed 
only at a right angle or a little more than a right angle with the 




Fig. 151. 



body, before the pelvis will be raised. The moment the pelvis 
begins to rise, that moment you have reached the limit of flexion. 

Adduction is very limited indeed. The diseased limb cannot 
be crossed over the opposite limb, and even by the time it has 
reached the median line the pelvis begins to move, showing that 
you have reached the extreme limit of adduction. 

Abduction, particularly if the limb is slightly flexed and at 
the same time rotated outward, can be carried to an extent some- 
what greater than adduction, but not to full abduction, before 
the pelvis will begin to move, showing that muscular rigidity is 
present. 

Now, in whatever position the affected limb must be held in 
order to bring the pelvis and trunk into a normal relation with 
each other, that is, so that the two lines mentioned shall cross each 
other at right angles and the spine be upon the table or floor — 
such position indicates the deformity present at the time of mak- 
ing the examination, and the stage at which the disease has arrived. 

In the first stage, therefore, as can be seen in these cases 
before you, the thigh is flexed very slightly upon the pelvis, and 
very slightly abducted ; and, the pelvis being held perfectly still, 
very limited motion can be made at the joint, when slight exten- 
sion is made upon the limb. Attempts to extend the limb beyond 
a certain point, as you now observe, tilt the pelvis ; flexion beyond 
a certain point — in this case not quite to a right angle with the 
body, in other cases it may be to more than a right angle— tilts 



SYMPTOMS IX FIRST STAGE. 239 

the pelvis ; whereas upon the well limb extension can be made 
complete, and flexion complete, so as to bring the knee against 
the trunk. 

Abduction, adduction, and rotation, are also limited, as you ob- 
serve, and when carried beyond a certain point the pelvis at once 
moves with the limb, giving the patient an appearance as if com- 
plete anchylosis had taken place at the hip-joint. But there is no 
real anchylosis present in this stage of the disease. There is 
anchylosis, perfect and complete to all appear<mce y but it is due 
simply to muscular rigidity. For, by placing the hand upon the 
pelvis, and making gentle extension upon the limb for a few sec- 
onds in the line of the deformity, motion can be made at the 
joint without causing pain ; but the moment extension is removed 
limited motion causes pain, the muscles suddenly become rigid, 
and the child can be rolled around like a solid marble statue. 

If the disease, however, has passed beyond the first stage, and 
effusion has taken place, then abduction is much more marked, and 
flexion is much stronger than in the first stage, but the peculiar 
feature of the deformity then is eversion or rotation of the foot 
outward. These symptoms will be more fully considered when 
we come to speak of the symptoms of the second stage. 

Another symptom of the first stage that is too often over- 
looked is atrophy of the thigh or entire limb. Therefore, always 
compare the limbs by actual measurement, for the rapidity with 
which atrophy takes place in some cases is really surprising, and 
is due to the direct influence of immobility of the joint. The 
symptoms, as we have studied them thus far, all point to one 
thing, namely, fixation of the joint, restraining motion as much as 
possible. This will occur without the slightest recognition of 
pain on the part of the patient, and is due to what Mr. Barwell 
terms " joint-sense." 

The symptoms of which the patient will complain are ten- 
derness and pain. Tenderness is usually well marked, although 
sometimes it is necessary to make a thorough examination of the 
joint before its presence can be detected. The disease may be 
situated at any part of the joint-surface, and we ought, before 
denying the existence of tenderness, to make pressure upon every 
part of the head of the femur or acetabulum that could have been 
involved in the original injury. 

This can be done by placing the thigh in all possible posi- 



2i0 DISEASES OF THE HIP-JOINT. 

tions, and at the same time making pressure upon the head of the 
bone and the acetabulum by crowding the articular surfaces 
together. 

In addition, pressure should be made upon the great tro- 
chanter in order to bring the head of the femur and acetabulum 
in contact from that direction. 

Again, holding the knee with one hand and fixing the pelvis 
with the other, press the thigh-bone upward. This manoeuvre 
generally causes pain, which can be detected in the patient's face, 
even when he denies he feels it. If the manoeuvre does cause 
pain, then observe whether or not extension relieves it. To make 
your examination doubly sure, if tenderness has not already been 
detected, sweep with the thigh its largest possible circle, by which 
means the head of the bone cannot possibly escape being brought 
in contact with every part of the acetabulum. 

Pain may or may not be experienced during the first stage, 
independent of motion or pressure upon the joint surfaces. 

In those cases where the disease manifests itself immediately 
after the injury — which cases are probably either synovitis or 
periostitis of the great trochanter — the pain is also immediate and 
constant, and frequently excruciating. 

In other cases, when probably the seat of the disease is in the 
articular lamella — either beneath the articular cartilage of the 
head of the bone or the acetabulum — pain is developed late in the 
first, or even not until the second stage. 

This pain may be referred more or less definitely to the hip- 
joint and its surrounding tissues, or it may be so entirely located 
in the knee as sometimes to completely mislead the surgeon in 
his diagnosis. I have many times seen the knee blistered and 
treated for months, when there was no disease whatever at that 
joint, it being merely affected by the disease in the hip. 

Mr. Barwell explains the knee-pain as follows : It is produced 
(1) by direct irritation of the nerves passing in close contiguity to 
the joint. These are the obturator nerves, the sciatic, the gluteal, 
and perhaps the anterior crural. It is produced (2) in consequence 
of an obscure sympathy between the two ends of the bone, or 
even direct propagation of the inflammation from one to the 
other ; and (3) by spasm of certain muscles. 

Such, gentlemen, are the symptoms by which you are to rec- 
ognize hip-joint disease in the first stage. 



SECOND STAGE. ' 241 

No one of them is entirely diagnostic. The certainty of the 
diagnosis depends npon a careful consideration of all the symp- 
toms described. 

We have thus dwelt upon them at some length, because many 
of them differ from those of more advanced stages only in degree, 
consequently require only one description ; but more especially 
because it is in this stage that the diagnosis is most difficult and 
important. In the later stages, it is almost impossible not to rec- 
ognize the disease, but the patient has then endured great suffer- 
ing, and perhaps irreparable mischief may have resulted, which 
might have been easily prevented had the true nature of the dis- 
ease been early recognized and properly treated. 



LECTURE XX. 

DISEASES OF THE JOINTS. MORBUS COXAKIUS (CONTINUED). 

Symptoms (continued). — Symptoms of the Second Stage and their Explanation. — 
Case. — Symptoms of the Third Stage. — Discussion of the Question of Dislocation 
in this Stage. 

Gentlemen : To-day we will continue the history of hip-dis- 
ease by first studying the symptoms of the second stage. 

The symptoms described at our last lecture as belonging to 
the first stage — namely, pain, tenderness, swelling, atrophy, and 
limited motion — continue into the second stage of the disease, but 
are generally increased in severity. 

The peculiar position of the limb gives to the second stage of 
.the disease the name " apparent lengthening," but I prefer to desig- 
nate it as the stage of effusion. 

If you examine the patient while in the standing position, as 
in our previous examination (see Fig. 148), it will be noticed that 
the foot is now everted, and the leg is a little more flexed upon 
the thigh, the thigh is a little more flexed upon the trunk, the 
obliteration of the gluteo-femoral crease a little more marked, 
and the entire limb more markedly abducted. 

The foot upon the affected side is somewhat in advance of the 
16 



242 



DISEASES OF THE HIP-JOINT. 



one upon the sound side, and the weight of the body of course is 
thrown upon the latter, as seen in Fig. 152. It is this tilting of 
the pelvis that produces the apparent lengthening of the limb. 
By careful measurement, however, it has • been shown that no 
lengthening whatever is present, but on the contrary, by reason 




Fig. 152. 



of the change of the relation of the anterior superior spine of the 
ilium to the femur, the distance from the former joint to the mal- 
leolus is slightly diminished. 

Why, then, does the limb assume this peculiar position ? It 
does so for the purpose of accommodating the effusion which has 
taken place within the capsule of the joint, and the deformity 
produced is explained in the following manner : 

If you will refer to the anatomy of the hip-joint (Fig. 141), it 
will be noticed that the ilio-f emoral ligament, extending from the 
anterior inferior spinous process of the ilium to the trochanter 
minor, lies in front of and is firmly united to the capsule, from 
above downward, forward, and inward, in such a manner as to 
cause it to remain in close contact with the bone. There is nor- 



ANCHYLOSIS FROM EFFUSION. 243 

mally a very small quantity of fluid within the capsule, and you 
cannot increase that amount without also increasing the capacity 
of the capsule, which is done by unfolding it, and that can only 
be accomplished by abducting and flexing the thigh, and rotating 
it outward. That is exactly what occurs when the joint is in- 
flamed and effusion takes place ; the capsule is unfolded and its 
capacity is thus increased, simply to accommodate the fluid effused 
within it, and that necessarily gives rise to distortion of the limb. 
This is the reason why the limb is always slightly flexed, abducted, 
and rotated outward. If the effusion becomes very great, the limb 
is more flexed, more abducted, and more rotated outward, and 
at the same time more fixed. The limb may be so rigid as to be 
apparently anchylosed, but it is only an apparent anchylosis, and 
simply depends upon a distention of the capsule and rigid muscu- 
lar contraction. 

That the mere presence of liquid in the perfectly closed joint 
is capable of producing such immobility and distortion is clearly 
demonstrated — 1. By the experiments of Prof. E. W. Weber, who 
injected the hip-joint through an opening in the pubic bone. By 
this procedure he invariably produced eversion, flexion, and ab- 
duction of the thigh, and immobility of the joint. The latter 
was so complete and unalterable that an attempt to overcome it 
either burst the capsular ligament or drove the stopper out from 
the artificial opening like a pellet from a popgun ; 2. By punct- 
ure of joints greatly distended with fluid, in which immobility 
and this peculiar distortion are both present, mobility and the 
proper position of the limb are at once restored. It should, how- 
ever, be borne in mind that these symptoms, eversion, abduction, 
and immobility, may sometimes be continued after the capsule has 
been ruptured. Then they depend upon the altered condition of 
the capsule and surrounding parts, for these have become thick- 
ened and adherent to each other, consequently more or less un- 
yielding, and necessarily retain the parts in their malposition. 

The characteristic symptoms, then, being due directly to the 
presence of liquid, synovia, pus, or lymph, within the capsule of 
the joint, the second stage is properly called the stage of effusion. 
The pain in this stage is much greater than in the first, and is 
aggravated by the inability of the capsule to perfectly accommo- 
date itself to the increased amount of effusion. 

If you will seize the knee of one of these patients in the sec- 



244 DISEASES OF THE HIP- JOINT. 

ond stage of hip-disease, who is suffering indescribable pain, and 
make slight- extension in the line of the deformity ', and, at the 
same time, slightly evert the limb, you will give almost instant 
relief, simply because you assist in accommodating the capacity 
of the capsule to the amount of the effusion. If the limb is 
abducted or extended in the line of the deformity without the 
eversion, the slightest degree of adduction will cause pain at 
once ; but, when everted, it may be abducted to a trifling extent 
without causing pain. 

But why does not the joint fully accommodate itself to the 
increased effusion within it, and how do we account for the great 
pain in this stage ? It is because there is a constant struggle 
going on between the adductor muscles of the limb and the over- 
distended capsule. The adductors are excited to constant con- 
tractions by the irritation communicated to them by the articular 
branch of the obturator nerve, which immediately supplies the 
joint. The action of these muscles, however, is resisted by the 
abduction and eversion of the limb, caused by over-distention of 
the capsule. The limb cannot yield to the traction of the adduc- 
tors ; neither can the joint perfectly accommodate itself to the 
increased effusion, and this constant struggle causes the intense 
pain which is referred to the point of distribution of the nerves 
involved. It occurs nearly always at night. The child becomes 
completely tired out, drops off to sleep for a minute or two, the 
muscles lose their hold upon the limb, the limb falls, causing 
movements at the diseased joint, and instanter there is a spas- 
modic contraction of the muscles which brings the diseased sur- 
faces together with a snap, and the child immediately awakes 
with a shriek. The mother or nurse hastens to the bedside ; but, 
perhaps, before it can be reached, the child has dropped off to 
sleep again, and this is repeated over and over. 

You can hardly appreciate this fact, unless you live in the 
hospital, or stay for several nights in a house where there is a 
child suffering from disease of the hip-joint in this stage. 

This pain, moreover, is self-perpetuating, for the irritation of 
the diseased joint causes the muscular contractions, and these, in 
turn, aggravate the inflammation and destructive changes within 
the joint, by constant pressure. 

The continued contraction of the adductors very frequently 
renders them hard, thin, wiry, under the finger, and able to 



CASE OF CONTRACTURE. 245 

resist any attempt to move the limb from its position. Some- 
times positive contracture takes place, and then subcutaneous sec- 
tion must precede any attempt at extension, as the following case 
illustrates : 

Case. — Sabina D., aged six, was brought to Bellevue Hos- 
pital in January, 1863. She was a well-formed child, and had 
always been perfectly healthy until August, 1861. Her mother 
states that she fell from the table, striking upon her right hip, 
which caused her considerable pain at the time ; in a few days 
she resumed her play as if nothing had occurred. This con- 
tinued until early in October, over two months from the receipt 
of the injury, when she was attacked with a severe pain in her 
knee, with a noticeable limp in her walk. The mother thinks 
she limped for some days before she complained of the pain. 
The pain was much more violent at night, the child frequently 
awakening her parents by her sharp screams. She was taken to 
St. Luke's Hospital, where she remained more than two months, 
extension being kept up during the whole time by weight and 
pulley without any benefit ; on the contrary, all her symptoms 
were aggravated. 

She was admitted to Bellevue Hospital, January, 1863, as 
before mentioned, when the following notes, as recorded by the 
house-surgeon, Dr. W. F. Peck, were taken : " Right foot, when 
she stands erect, is four and a half inches from the floor, and 
very much adducted ; the leg is flexed upon the thigh slightly, 
and the thigh upon the pelvis. {See Fig. 153.) When the 
slightest motion of the femur is attempted, the pelvis moves 
with it, as though bony anchylosis existed ; constant pain at the 
hip-joint, which is increased by pressure ; leg atrophied. Exten- 
sion was applied for a few days, but the pain was so great, and 
no improvement in position following it, that Dr. Sayre subcuta- 
neously divided the gracilis and adductor longus muscles. The 
wounds were immediately covered, and moderate extension ap- 
plied to the limb. When comparing the length of the two legs, 
the diseased one was found nearly an inch shorter than its fel- 
low. 

" January 30th. — The extension now gives her perfect relief 
from pain. Before the operation, it was torture when the exten- 
sion was continuously applied. She eats and sleeps well. 

" February 2d. — Wound made by the tenotomy perfectly 



246 



DISEASES OF THE HIP-JOINT. 



healed. As long as extension is kept up, she feels no pain. 
Appetite and digestion perfect. 

"16th. — Sayre's short hip-splint was applied this afternoon, 
when she walked without difficulty. 

" April Uh. — Patient was brought to hospital to-day, to have 
her dressings reapplied, as they had not been moved since she 





Fig. 153. 



Fig. 154. 



left the hospital. Improvement most marked ; instead of the 
peevish, irritable disposition she manifested when first admitted, 
she is now cheerful and happy, and the glow of health is upon 
her cheeks. Her mother states that she has not complained of 
pain since she left the hospital. Her present condition can be 
seen in Fig. 154, taken from a photograph." 

The immobility which is present in the second stage, result- 
ing from over- distention of the capsule and muscular rigidity, 
is usually well marked. The muscular contraction, however, is 
reflex in character, and is for the purpose of keeping the joint 
perfectly still. There is apparent anchylosis, but it is only ap- 
parent. 

Motion is much more painful than rest, even when rest is ac- 
companied by pressure produced by muscular contraction. Hence 
the patient, naturally choosing the least of two evils, obtains 



THIRD STAGE. 247 

rest of tlie part by means of this muscular rigidity, although it is 
done at the expense of absorbing the tissues by pressure, and at 
the same time gives rise to hectic and exhaustion. 

The flexor muscles of the thigh, the pectineus, the tensor 
vaginae femoris, and the rectus femoris, are so firmly contracted 
that the whole pelvis moves upon the opposite acetabulum ; in 
short, the ilium of the opposite side may be distinctly seen to 
move when any attempt is made to rotate, adduct, or abduct the 
diseased limb. Even under chloroform, this motion takes place 
unless firm extension is made before the trial is begun, as I have 
seen in several instances, and even then the motion is only very 
limited. 

Let us next study the symptoms of the third stage. 

If the disease is not arrested, the acetabulum becomes per- 
forated, or ulceration and rupture of the capsule take place, 
and the imprisoned fluid escapes into the surrounding tissues. 
When this has occurred, the disease is in the third stage, and the 
patient is comparatively free from pain. In the majority of 
instances the effusion soon burrows in various directions, and 
finally produces one or more openings upon some portion of 
the thigh, and in some instances at some distance from the affect- 
ed joint. 

It is often thought that a great deal has been gained because 
the patient is so much more comfortable, after rupture or perfo- 
ration has taken place, whereas the disease has only gone on to 
the third stage, in which effusion takes place into the surround- 
ing tissues instead of being retained in a closed sac around the 
joint. 

Almost immediately, however, there is a marked change in 
the character of the deformity. The limb is now adducted, in- 
verted, and flexed, very often at the hip only. The pelvis is 
raised upon the affected side, which brings the corresponding 
natis above that of the sound side, causing it to project backward, 
and now the gluteo-femoral fold is higher than upon the sound 
side or obliterated altogether. The position of the limb, as you 
see, is in most respects the reverse of that seen in the second 
stage {see Fig. 155). 

The change in position is due to the fact that the fluid con- 
tained in the cavity of the joint has been evacuated. The dis- 
tention of the capsule, which was the mechanical cause of the 



248 



DISEASES OF THE HIP-JOINT. 



eversion and abduction of the limb, having been relieved, nothing 
now obstructs the full action of the adductors, and the limb is 
therefore adducted and inverted. The equilibrium of the body 
is preserved by raising the pelvis so as to bring the centre of 
gravity over the sound foot. The loss of substance in the head 
of the femur and the acetabulum accounts for the actual shorten- 
ing that occurs, and the tilting of the pelvis makes it appear even 




Fig. 155. 



greater than it is. Since the foot of the affected side no longer 
touches the ground, the flexion of the knee is unnecessary, and 
therefore often disappears. 

This change from the second to the third stage is sudden 
when there are no adhesions in the surrounding tissues (as al- 
ready indicated), and when the opening in the capsule is large 
and allows of the rapid and total escape of its contents into the 
surrounding tissues. But if the rupture is very small, perhaps 
fissure-like, the fluid oozes out by slow degrees, consequently the 
change in the deformity will take place slowly. 

I have seen the change take place in a single night, while in 



COMPARISON OF SECOND AND THIED STAGES. 949 

other cases it may require weeks for its completion. There are 
extreme cases in which this change does not take place at all, 
although the effusion has escaped from the joint. . Those are the 
cases in which the head of the bone has broken through the ace- 
tabulum, and is held firmly in the opening, or those in which in- 
flammatory adhesions, osteophytes, etc., have taken place between 
the bones comprising the joint, holding it in its false position 
even after the capsule is ruptured. 

For convenience of reference the symptoms of the second and 
third stages of hip-disease are placed side by side below (Bauer). 

Second, Stage. Third Stage. 

Limb (apparently) longer. Limb shorter. 

" abducted. " adducted. 

" everted. " inverted. 

" flexed in both joints. " flexed in hip-joint only ; may be 

flexed at knee-joint also, but not 
necessarily. 
Foot touches the ground with sole. Foot touches with ball only. 
Toes everted as in fracture of neck. Toes inverted as in posterior superior 

luxation. 
Pelvis lowered on diseased side. Pelvis raised. 

" projected forward. » projected backward. 

" angle of inclination acute. « angle of inclination almost 

right. 
Natis low and flat. Natis high and round. 

Linea inter nates inclined toward af- Linea inter nates deviates from affect- 

fected side. ed side. 

Pain most intense. Pain greatly diminished. 

It was long believed that this change of symptoms was due to 
a real dislocation of the head of the femur upon the dorsum of 
the ilium, brought about by the gradual destruction of the upper 
rim of the acetabulum by caries, thus allowing the head of the 
bone to escape from the socket. 

The first to challenge this theory was the late Dr. Alden 
March, of Albany, New York. 

In his paper upon this subject read before the American 
Medical Association, and published in their " Transactions " for the 
year 1853, he established the fact that dislocation does not really 
take place. 

Dr. March said : " It has been my privilege to examine the 
specimens of this disease in the London University Hospital Mu- 



250 DISEASES OF THE HIP-JOINT. 

seum, where Mr. Bell's morbid specimens are deposited, and yet 
I could discover no preparation of "hip-disease" where it ap- 
peared in the least degree as though the head of the femur was 
luxated during the life of the patient." 

In fact, the profession in this country are indebted to Dr. 
March for the first clear, comprehensive, and correct statement of 
the pathology of this disease; and the basis was laid down by 
him for the proper plan of treatment, from which all improve- 
ments in the treatment have since been developed. 

We need only refer to the following well-known text-books 
upon surgery to show that our best authorities have always con- 
sidered the peculiar deformity, which occurs in what has been 
described as the third stage of the disease, to be dependent upon 
a true luxation of the head of the femur upon the dorsum of the 
ilium, and not upon muscular contraction, twisting of the pelvis, 
enlarged acetabulum, and diminished head of the femur from 
progressive absorption of bone, which I believe to be the true 
explanation. 

R. Druitt, in his "Principles and Practice of Modern Sur- 
gery," says in his chapter upon hip-disease : " But, if the disease 
proceed, it is succeeded by another kind of shortening, caused 
either by the destruction of the neck of the femur by caries, or 
(as is more commonly the case) by the destruction of the acetabu- 
lum and capsular ligament and dislocation of the done upward 
by the muscles." 

James Miller, in his " Practice of Surgery," under the head 
of morbus coxarius, says: " As disorganization advances within, 
the joint becomes more and more loose, and dislocation may 
occur by muscidar action alone, without the intervention of a 
fall or other injury. The dislocation is usually upward on the 
dorsum of the ilium." 

Sir Charles Bell, in his "Institutes of Surgery," remarks: 
" Another peculiarity, in the position of the patient with diseased 
hip, is that of throwing the thigh of the affected side over the 
other, that the head of the thigh-bone becomes as a lever loaded 
at the lower end, by which the upper end is raised and the press- 
ure taken off the inflamed glenoid cavity. It is a position of 
great relief ; but the consequence is actual dislocation in extreme 
cases." 

Baron Dupuytren, in the "Injuries and Diseases of the 



SUPPOSED DISLOCATION. 251 

Bones," subject, " Congenital Dislocation," says : " Whatever 
importance may be attached to this dislocation in the abstract, it 
is deserving of still more attention on account of its presenting 
all the signs of luxation consequent on disease of the hipjoint, 
with which it has always been confounded? In another place he 
remarks: "It" (congenital dislocation) "does not include that 
painful and cruel disease of the hip-joint which usually results in 
spontaneous dislocation of the femur? 

Chelius, Peine, Liston, Samuel Cooper, and Gibson, all agree 
with the authors above quoted in regard to the spontaneous luxa- 
tion of the femur in the latter stages of hip-disease. 

And even Sir Astley Cooper, in his treatise on " Dislocations 
and Fractures of the Joints," says : " Dislocations may arise from 
ulceration, as we frequently find this state of the parts in the 
hip-joint : the ligaments ulcerated, the edge of the acetabulum 
absorbed, the head of the thigh-bone changed both in its magni- 
tude and figure, escaping from the acetabulum upon the ilium, 
and thus forming for itself a new socket." 

Yet, none of the above authors, although so positively stating 
that luxation occurs in the disease, have sustained their assertions 
by the evidence of a single post-mortem examination. 

These references could be increased, but quotation has been 
made from a sufficient number to establish the fact that the idea 
of luxation in hip-disease has been one of almost universal adop- 
tion. Yet, whenever any one of them has made a post mortem, 
or has cut into the joint for exsection, he has invariably found 
that no luxojtion had taken place, but that the "head of the 
femur was still within the capsular ligament," much absorbed, 
probably, and frequently separated from the shaft of the fernur 
entirely, thus permitting the trochanter major to slip upon the 
dorsum of the ilium ; and this no doubt has been mistaken for 
true luxation. I have seen this condition of the parts very many 
times, and seen the mistake made by most excellent surgeons. 
At other times the acetabulum has been found " much enlarged 
by absorption, and extending upward and backioard, as if Nature 
had made an attempt to form a new joint in this direction? 

As the upper portion of the acetabulum is absorbed by the con- 
stant pressure, the periosteal inflammation, which is present at 
the same time outside of the joint, is constantly throwing out 
new material, and we even find firm osteophytes of considerable 



252 



DISEASES OF THE HIP-JOINT. 



magnitude. Tims, as the progressive absorption goes on within 
the joint, there is a constant deposition taking place outside of 
the joint, by which means the acetabulum with the capsular liga- 
ment and contents is, as it were, slipped upward upon the dorsum 
of the ilium ; so that, instead of a luxation of the hip, we have in 
fact a displacement of the acetabulum itself. {See Fig. 156.) 




Fig. 156. 



As long as the acetabulum retains the remnants of the head 
of the femur within its cavity, it should not be called luxation of 
the femur. Now, if the disease is of long standing, the ace^ 
tabulum is frequently perforated, the synovial membrane and 
cartilages more or less destroyed by ulceration, the bones become 
carious or necrosed, the ligamentum teres is invariably destroyed, 
and the joint is filled with pus ; or the capsular ligament may be 
perforated by ulceration at one or more places through which the 
pus has escaped, and this generally occurs at the inner and lower 
border of the acetabulum. This, according to my observation, has 
been the real pathological condition of this stage of all the cases 
that I have examined, and it accounts very satisfactorily for the 
shortening and other appearances of luxation. If, for example, 
the head of the femur is diminished by absorption three-fourths 
of an inch in length, as is often the case, and the acetabulum is 
extended upward and backward to the same amount, the gluteal 



POST MORTEM. 253 

and other muscles holding the bones in close contact, there will 
be produced an inch and a half of shortening of the limb ; and 
then twisting of the pelvis upon the trunk will increase this 
shortening, and produce the other symptoms which have been 
mistaken for evidences of luxation. 

To illustrate my position, I will quote a post-mortem exami- 
nation from Sir Benjamin Brodie's work on " Diseased Joints," 
published in 1834 : 

" A middle-aged man was admitted to St. George's Hospital, 
in the autumn of 1805, on account of a disease of his left hip. 
He also labored under other complaints, and died in the February 
following. On inspecting the body, the soft parts in the neigh- 
borhood of the joint were found slightly inflamed, and coagulated 
lymph had been effused into the cellular membrane round the 
capsular ligament. There were no remains of the round ligament. 
The cartilages had been destroyed by ulceration, except in a few 
spots. The bones, on their exposed surfaces, were carious ; but 
they retained their natural form and size. The acetabulum was 
almost completely filled with pus and coagulated lymph; the 
latter adhering to the carious bone, and having become highly 
vascular. The head of the femur was lodged on the dorsum of 
the ilium. 

The capsular ligament and synovial membrane were much 
dilated, and at the superior part their attachment to the bone was 
thrust upward, so that, although the head of the femur was no 
longer in the acetabidum, it was still within the cavity of the 
joint" 

Here we have the testimony of Sir Benjamin Brodie that " the 
head of the femur was lodged on the dorsum of the ilium" and in 
almost the next sentence he says "It was still within the cavity 
of the joint." Comment seems to me unnecessary, for this can- 
not be called luxation according to the ordinary definition of that 
term. 

In Braithwaite's " Pvetrospect," No. 22, January 7, 1855, p. 196, 
is the report of a case of exsection of the head of the femur for 
"hip-disease," by Mr. S. Key. After giving the age, sex, and pre- 
vious condition of the patient, he describes her condition on ad- 
mission to the hospital, and says: "The left femur was dislocated 
on the dorsum ilii, the limb shortened and the leg and thigh 
flexed." After consultation,. " it was considered that removing the 



254 DISEASES OF THE HIP-JOINT. 

head of the bone would give the patient the best chance of re- 
covery." He then describes the operation and the morbid appear- 
ances he observed about the joint. He states that " the acetabu- 
lum was found to have enlarged by absorption and was extended 
in a direction upward and backward^ as if an attempt had been 
made by Nature to form a new joint in this direction. The bead 
of the femur had been entirely absorbed; a portion of the neck 
remained, which with the great trochanter was the part removed." 
I would simply ask how it could be possible that there was a " dis- 
location on the dorsum ilii," if " the head of the femur was en- 
tirely absorbed ? " Can a bone be luxated when it has no exist- 
ence ? The answer it seems to me is perfectly plain, and it is that 
the luxation never took place, the apparent luxation being due to 
the absorption of the bone. 

I do not deny that luxation can take place in morbus coxarius 
as well as in a healthy joint ; but, on the contrary, a much less 
amount of force ought to be able to produce it. If, however, the 
nurse, while lifting the patient out of bed, or by twisting the leg 
across the opposite limb, ruptures the capsule and produces a luxa- 
tion (as I have seen done), it is as much a traumatic luxation as if it 
had been produced by a fall from a house or by any other accident. 
And if a careful inquiry is made in all cases of so-called " spontane- 
ous luxation" we shall find that they have occurred after the appli- 
cation of violence more or less severe, and not as the result of un- 
aided " muscular contraction " according to Miller and the other 
authors whom I have quoted. 

I have now performed exsection of the hip-joint fifty-nine times, 
and have found luxation in only one case, that of M. D. Field, 
and it was caused a few days previous to the operation by the 
nurse twisting his leg while getting out of bed. 

Prognosis. — This will be varied very much by the constitu- 
tion of the patient previous to the occurrence of the disease, or 
more particularly by the treatment adopted, and the stage of the 
disease at which it is commenced. 

In the earlier stages, before organic changes have taken place, in 
consequence of inflammatory processes or disintegration by caries, 
if a proper course of treatment is adopted a most favorable result 
may be predicted ; for recovery usually takes place with a useful 
joint. If the second stage has continued for some time before 
treatment is begun, the effusion into the joint may have become 



PROGNOSIS. 255 

organized, or adhesion taken place, which will remain after the 
disease has entirely subsided. Under these circumstances recovery 
will take place with some deformity, and anchylosis more or less 
complete. This will demand subsequent treatment according to 
the condition of the patient, and to decide what is the best treat- 
ment that can be adopted requires the greatest skill and judgment 
on the part of the surgeon. 

If the disease has progressed until it has reached the third 
stage, before treatment is commenced, you should not promise 
recovery without deformity and impaired motion. These cases 
sometimes recover, after applying the proper mechanical appara- 
tus, but almost always with more or less complete anchylosis and 
deformity. But, if, after proper treatment, the disease still pro- 
gresses, there is nothing left for the surgeon to do but exsect 
the joint, thereby removing the carious bone both of the femur 
and acetabulum. If this operation is properly performed, it can 
be done without danger; and, with judicious after-treatment, 
will, in a large majority of cases, result in a useful joint. 

When, however, the case is seen during the first, or early 
part of the second stage of the disease, and put under proper 
treatment, as a rule, far different results may be expected, as we 
will have abundant occasion to show you that they frequently 
recover without deformity, and with perfect motion. 

If the disease is allowed to progress without proper treatment, 
it ordinarily runs through the three stages. 

Occasionally a patient is seen who has been cured by anchy- 
losis in the second stage, and he is thus compelled to carry this 
deformity through life. 

These instances, however, are very rare. If, as is generally 
the case, when proper measures have been neglected, abscesses 
have formed after rupture of the capsule, one of two terminations 
is to be expected — care by anchylosis with deformity, or death. 
The former sometimes occurs, but only a minority will be found 
with a sufficiently strong constitution to sustain the excessive 
drain of the long-continued suppuration. 

If, however, the patient has the benefit arising from recent 
improvements in the appliances used in the treatment of this dis- 
ease, a far different result may be hoped for and expected, if the 
treatment oe not delayed until too late. If the patient has already 
advanced to the third stage, and is much reduced, death may 



256 



DISEASES OF THE HIP-JOINT. 



ensue, or the best result may be anchylosis ; but, even here, by 
proper treatment, a majority may be saved, and we may expect 
to secure a case with partial, often complete, motion in the joint, 
as the following case illustrates : 

Case. — Katie K., nine years old, was brought to Bellevue 
Hospital Medical College, January, 1875, in robust health, but 
with her right hip anchylosed in the position seen in Fig. 157, 
from a photograph taken by Mr. Mason at the time. She had 





Fig. 157. 



Fig. 153. 



fallen down-stairs when she was five years of age, bruising her 
right hip, which was almost immediately followed by all the 
usual symptoms of hip-disease. She was treated by repeated 
blisters and internal remedies, but no extension or counter-exten- 
sion was employed to prevent deformity. After three years of 
excessive suppuration, she eventually recovered with the limb 
anchylosed, in which condition she has been for the past twelve 
months. 

As she was in perfect health, no suppuration existing at the 
time, I put her under chloroform, divided the adductor longus 
and tensor vaginae femoris muscles, with some bands of con- 
tracted fascia, broke up the adhesions, and placed her in the wire 



TREATMENT. 257 

cuirass before the class, January 13, 1875. No untoward symp- 
toms followed, and, February 2d, she was removed from the wire 
cuirass, and a long hip-splint applied (see Fig. 158), by the aid of 
which she could walk perfectly well without a cane. The motions 
at the joint were quite free, but the psoas magnus and iliacus 
internus muscles are not fully extended, which produces the 
slight curve which is noticeable at the sacro-lumbar junction ; she 
can abduct the limb to nearly the normal extent, and is able to 
flex the thigh to an acute angle. 



LECTURE XXI. 

DISEASES OP THE JOINTS. MORBUS COXARIUS (CONTINUED). 

Treatment. — Mechanical Apparatus, and how applied. 

Gentlemen : We have arrived at the subject of Treatment 
in our study of hip-disease, and that will engage our attention 
this morning. 

The treatment of morbus coxarius may be divided into — 

1. Local; 

2. General. 

Many of the general remedies employed have been given to 
counteract the scrofulous diathesis which was supposed to under- 
lie these joint-diseases. Of course, if the disease occurs in a 
patient who happens to be scrofulous, it will be necessary to 
bear in mind the diathesis which complicates the trouble, and 
employ the proper remedies. But, as has already been shown, 
these " white swellings " of joints have no necessary connection 
with scrofula, and occur indifferently in the weak and the robust, 
according as the exciting causes, generally traumatic, are brought 
into action. It would, then, be highly illogical to subject every 
case of joint-disease to a course of anti- scrofulous medication. 
You will, however, generally find that these patients are benefited 
by those remedies, such as tonics, cod-liver oil, and stimulants, 
which are of value in the treatment of any disease of long dura- 
tion and debilitating tendency. 



258 DISEASES OF THE HIP-JOINT. 

No more exact rule, I think, should be laid down than this : 
vary jour medication according to the actual demands of each 
case, and do not base it upon a theoretical morbific cause which 
you desire to combat. I shall, therefore, simply recall the means 
which are usually of most benefit in the way of general treat- 
ment. 

First, see that the patient has sufficient food, and that it is 
properly assimilated. A very common difficulty in these cases is 
that, even before the appetite fails, the food taken into the stom- 
ach is not properly digested. 

It may be mentioned here, that the local means employed for 
quieting the pain and allaying the destructive processes within 
the joint are generally the best remedies for restoring the appe- 
tite and assisting digestion. But you must see to it that your 
patient has food that is highly nutritive and easily assimilated. 
Endeavor to regulate the condition of the bowels, by varying the 
food according as constipation or a tendency to diarrhoea exists. 
Cod-liver oil, so commonly used in these affections, I am confi- 
dent, owes its efficacy simply to its nutritive rather than to any 
particular medical property. 

Again, observe the hygienic surroundings of the patient. If 
you find him under the influence of bad ventilation, noisome 
exhalations, or, above all, deprived of sunlight, endeavor to cor- 
rect and improve his condition in these respects. Look to all 
these things ; for, while I am a strong advocate of the efficiency 
of local treatment, you cannot expect to succeed in the face of 
adverse hygienic surroundings and insufficient and improper food. 
As regards medication proper, I know of nothing demanded be- 
yond the usual tonics and stomachics found to be of service in 
other diseases. I would mention particularly the use of baths ; 
sea-bathing in warm weather, when it can be had, or its substi- 
tute, saline baths, with friction, to stimulate the skin, when the 
open-air bath is beyond reach, or when the weather is too cold 
for its use. With this brief outline of general treatment, I shall 
pass to the consideration of local treatment. 

The only local treatment in use till within a few years was 
the application of counter-irritants, blisters, issues, setons, etc., 
over the affected joint. It was customary to leave the joint it- 
self to the vis medicatrix naturaz, a force that was sometimes 
found so conservative as to save the life of the patient, but pre- 



TKEATMENT. 259 

serving for him a withered, malformed, anchylosed limb, speci- 
mens of which yon now see before yon. It was an opinion enter- 
tained by some surgeons of respectability that, if the bones of 
the joint become involved in caries, there is little or no hope for 
the patient. Even so high an anthority as Mr. Syme asserted 
that, "if the head of the femur be carious" (which implied, in 
his estimation, a carious condition necessarily of the acetabulum), 
u the patient must die ! " But, it affords me great pleasure, gen- 
tlemen, to be able to-day to disprove, in the most unanswerable 
manner, the broad assertion of Mr. Syme ; and this pleasure does 
not arise from a consideration of being able to point out the 
errors and refute the statements of so deservedly great a man, 
but rather from the fact that I am able to give you such tangible, 
such cheering evidence of the progress of conservative sur- 
gery. 

The local treatment which has grown into favor during the 
past few years, but which I have advocated earnestly for the past 
twenty-five years, depends upon the necessity of giving absolute 
rest and freedom from pressure of the parts involved in the dis- 
ease, without materially interfering with the mobility of the 
joint. 

Bonnet's method — fixation without extension — for local treat- 
ment has been the plan abroad. In this country, however, fixa- 
tion with extension has been chiefly employed, and, to afford an 
apparatus that would meet these, indications, leathern splints, 
gypsum and starch bandages, and strong wire gauze, moulded to 
fit the limb, have all been employed with more or less benefit, 
but all these plans prevented mobility. 

Fixation with extension, I think, was first employed in 1825 
by Dr. Harris, of Philadelphia. His apparatus, however, neces- 
sitated confinement to the bed for a long time, and, as a conse- 
quence, the patients became cachectic, and the disease progressed 
to an unfavorable or fatal termination in many cases, despite the 
relief from pain given by the extension and fixation. 

The treatment by extension was an unavoidable inference 
from the demonstrations made in the paper of Dr. Alden March, 
already referred to, upon the cause of the apparent dislocation in 
the third stage of coxalgia. But, if the patients are kept upon 
the straight splint, as recommended by Dr. Harris, of Philadel- 
phia, or Dr. March, of Albany, and extension is maintained in 



260 DISEASES OF THE HIP-JOINT. 

addition to the fixation, we will relieve our patients from all 
suffering, it is true, and generally arrest the disease ; but, unless 
the greatest care be observed, and in the latter stages the patient 
be frequently removed from the apparatus and passive motion 
employed, it will almost invariably happen that anchylosis, more 
or less complete, will be left, and, so far as progression is con- 
cerned, the patient is in a much worse condition than when left 
to Nature. To obtain, then, permanent extension of the joint 
without a damaging amount of confinement, or, in other words, 
extension in such a manner as to permit motion, becomes the 
problem to be solved by surgical ingenuity. 

There are many cases in which the inflammation is so violent, 
and the pain upon the slightest movement so intense, that abso- 
lute rest is requisite for a time, and in such cases the fixed dress- 
ing alluded to answers a most excellent purpose. Under these 
circumstances I employ most commonly the cuirass with exten- 
sion. (See Fig. 190.) But motion is as essential in retaining a 
healthy condition of the structure about a joint as light is essen- 
tial in retaining a healthy condition of the eye ; for the liga- 
ments around a joint will become fibro-cartilaginous, or even 
osseous, if motion is denied them, particularly if a chronic inflam- 
mation is going on within the joint with which they are connect- 
ed. It was in consequence of such accidents occurring in several 
instances that I was led to contrive some plan by which exten- 
sion could be maintained that would remove pressure from the 
acetabulum and the head of the femur, and at the same time per- 
mit motion of the joint, thereby retaining the capsular ligaments. 
in a healthy condition. 

I never succeeded to my satisfaction in my efforts to attain 
this desideratum until Dr. H. G. Davis, of this city, applied to 
one of my cases an instrument which he had devised that an- 
swered the purpose admirably, and in its construction embraced 
the very principles which I had so long sought to apply. 

As Dr. Davis is, I believe, the first person who constructed 
an instrument embracing these important advantages — extension 
with motion — I have given him full credit for the same with a 
plate of his instrument, and his own remarks in respect to the 
method of its application, in my report to the American Medical 
Association in 1860. 

I have since made, as I think, some very important improve- 



OKIGINAL SPLINT. 261 

ments and modifications of this instrument, which I will describe 
more fully hereafter. 

As Dr. Davis since that time has taken out a patent on his 
instrument, and as others have since been devised by various per- 
sons that are so much more efficient without the objectionable 
features of Davis's original instrument, it is not necessary to make 
any further reference to it. The instrument of Dr. Davis was 
applied in the case referred to, with the happiest results for a 
few days, but it soon began to excoriate the groin ; and also the 
method of extension was not satisfactory, and could not be con- 
trolled at will. It would be either too feeble or too severe, and 
I therefore had an instrument constructed embracing all the 




Fig. 159. 

principles of the instrument devised by Dr. Davis, but which 
could be worn with much more comfort to the patient, was much 
more effectual, and was entirely under the control of the surgeon. 
The instrument I then devised consisted of a narrow steel splint, 
extending from just above the crest of the ilium to within two 
or three inches of the external malleolus, and was divided into 
two parts at the knee, so that one ran into or by the side of the 
other, and was capable of being extended at will by a ratchet and 
cog-wheel near the knee, that was worked by a key. The upper 



262 DISEASES OF THE HIP-JOINT. 

portion of the instrument was corrugated to increase its strength, 
and in a groove at its upper extremity was a ball-and-socket- joint 
to which was attached a pulley or wheel for the counter-extend- 
ing catgut cord to play through. This catgut was attached at 
either end of the perineal band, or counter-extending belt, which 
was made of thick India-rubber tubing, and, being firmly secured 
at either end, made an elastic and comfortable air-cushion for the 
perinaeum, and could be worn without excoriating or chafing the 
parts. At the lower end of the instrument was a small roller, ex- 
tending nearly its entire width, and just above it a buckle for the 
purpose of securing the firm webbing or strap which plays over 
the roller at the lower end, and was sewed fast to the strong ad- 
hesive plaster for the purpose of making extension. (See Fig. 159.) 

Such is a brief description of the instrument I first devised for 
the treatment of hip-joint disease. Since that time I have im- 
proved it in many respects, and the instrument I now most com- 
monly employ is a short thigh-splint, as seen in Fig. 160. 

The following is a description of this instrument, together with 
the method of application : 




Fig. 160. 

It consists of a pelvic band, passing partly around the body at 
the crest of the ilium, well padded on its inner surface, to which 
one or two perineal straps are fastened for counter-extension ; its 
outer surface holds a ball-and-socket joint, from which runs a 
steel rod or bar down the outer side of the thigh to within about 
two inches of the lower end of the femur. This outer bar is 
divided into two sections, one running within the other, and 
gauged or controlled by a ratchet and key, which can make it 
longer or shorter. At the lower extremity of this outer bar is 
a projecting branch going around to the inner surface of the thigh 
to receive the attachments of the plaster, hereafter to be described. 



APPLICATION OF EXTENSION". 



263 



Both of the lower extremities terminate, as you observe, in a 
cylindrical roller, over which the tags of the plasters are attached 
to the two buckles placed at the lower ends of the instrument. 

When the short splint is used, some means must be employed 
for making extension during the night, and also at other times 
when it is expedient for the patient to lie in bed. This is best 
effected by means of weight and pulley. 

To apply it, cut two strips of strong adhesive plaster, two or 
three inches wide, according to the size of the patient's leg, and 
long enough to reach from the malleoli to six or seven inches 
above the condyles of the femur. To the lower end of each strip 




Fig. 162. 



Fig. 163. 



sew a piece of strong webbing three or four inches long. (See 
Fig. 161.) 

After smoothly bandaging the foot and ankle, apply the ends 
to which the tabs are attached, one just above either malleolus, and 
carry the strips of plaster up the inner and outer sides of the leg 
and thigh, and secure them with a roller, nicking the edges of the 
plasters to make them fit smoothly, and prevent any folding or 



264: DISEASES OF THE HIP-JOINT. 

The proper method of fastening the plasters to the limb is to 
allow them to hang loose along the sides, and bring them in con- 
tact with it by the successive turns of the roller, for in this way 
yon will be much less liable to wrinkle them, and that is an im- 
portant item. This may appear to you like an insignificant mat- 
ter, and hardly worthy of special mention ; but it is not, for a 
single wrinkle in the adhesive plaster may, by the irritation it will 
produce, defeat the w^hole plan of treatment. 

The tabs should receive a few extra turns of the roller, over 
one and under the other, weaving them in, for the purpose of 
making them additionally secure. 

When the knee is reached by the roller, always cover it in 
with the figure-of-8 turn, for the edge of a reverse in the bandage 
at this place may give rise to serious inconvenience, and necessi- 
tate its entire removal. 

When the bandage has been carried two or three inches above 
the condyles, the remaining portions of the plasters are to be re- 
versed (see Fig. 162), and then a few more turns of the roller will, 
by the bandage adhering to the plaster, fix the dressing so that it 
will not easily slip. (See Fig. 163.) 

The plaster should be applied cold, but when the bandage has 
been applied the plaster should be moulded to the limb by firmly 
squeezing it with the hand. It is also very important to secure 
the plaster above the condyles of the femur, in order that exten- 
sion may be made upon the thigh and not ujpon the lateral liga- 
ments of the knee-joint. 

The bandage should then be fastened, and with stitches, for it 
is to remain a long time. 

If the limb is held in the proper position, namely, in the line 
of the deformity, and gentle extension maintained by an assistant, 
it can be prepared for the bed-extension and the splint without 
giving the child any pain. 

Next take a piece of thin board about three inches long and 
two or three inches wide, and arrange across it a piece of tape or 
webbing so that it shall project three or four inches upon either 
side. To the ends of these tabs fasten buckles or buttons, that 
they may be attached to the ends of the tabs upon either side of 
the limb. 

A simpler and more efficient method, for the board is liable 
to turn out of position, is to take a round piece of wood three or 



NIGHT EXTENSION. 



265 



four inches long, and having a groove in the centre for the attach- 
ment of the cord, and also one on each extremity to hold it in 
place, where it is buttoned into button-holes made in the lower 
part of the tabs attached to the strip of adhesive plaster already 
fastened to the sides of the limb. To the middle of this foot- 
board, or round stick, is attached a stout cord. The object of the 
board or stick is simply to prevent the bands from making un- 
comfortable pressure upon the malleoli. At the foot of the bed 
a pulley is to be arranged in such manner as the ingenuity of the 
surgeon dictates, the cord from the foot-board placed upon it and 
a weight attached, just sufficient to make such extension as will 
render the patient comfortable. 

For a weight, a bag of shot or sand is most convenient, because 
the amount can then be very easily regulated. 

To prevent the patient from slipping down in the bed, it should 
be raised ten or twelve inches by means of bricks or blocks. {See 
Fig. 164.) 

The foregoing is for night extension ; to apply an instrument 
for extension while the patient is exercising, the limb should be 
prepared in the following manner : 

First cut two triangular or fan-shaped pieces of adhesive plas- 




ter, the broad extremities of which should be wide enough to 
cover about half the surface of the upper part of the thigh, and 
are to be slit into strips an inch or more in width, for the pur- 
pose of permitting a more perfect adjustment, and, also, to be 
reversed in detail over the bandage. They should be of sufficient 
length to reach from the knee to the groin. To the narrow ends 
of these fau -shaped pieces you will sew a piece of stout tape or 
webbing, something non-elastic, three or four inches in length 
and as wide as the cylinder at the lower extremity of the in- 
strument. {See Figs. 165 and 166.) 



266 



DISEASES OF THE HIP-JOINT. 



Next, place the instrument upon the thigh with its jaws about 
three. inches above the condyles, and with the thumb and finger 





Fig. 165. 



Fig. 166. 



grasp the limb at the point upon either side where the instru- 
ment comes in contact with it. These two points indicate exactly 
where the tabbed ends of the fan-shaped pieces of adhesive plaster 
are to be applied. {See Fig. 167.) 

Now, having placed the tabbed extremities over these points, 
secure them in position with the roller-bandage by first making 
a few extra turns near the tabs, and then carry the bandage 
snugly and smoothly over the plaster upon the thigh, until the 
perinseum is reached, when the strips of plaster which are now 
floating loose are every other one to be reversed as the bandage 
goes around the thigh {see Fig. 168), continuing the bandage at the 
perinsBum until all of the strips of plasters are reversed, and then 
the bandage is carried down the thigh until the plasters are en- 
tirely covered. {See Fig. 169.) 

The effect of all this is to hold the dressing firmly in place. 

The thigh is now ready for the splint, and, after the shaft has 
been shortened as much as it can be, we will place it in position 
with the pelvic cross-bar, at the upper end, just under the crest 
of the ilium. 

Now, fasten the lower extremity of the splint first, and this 
is done by passing the tabs around the little cylinders in the jaw 
upon either side, buckling them as high as possible, and then 
buckling the strap that passes behind the thigh. Next buckle 
the perineal band, drawing it snugly, but not too tightly, and see 
that the smooth side is next to the skin. It is well, also, to lay a 
piece of old linen in the groin under the band, to protect the 
parts from pressure, and also to absorb the moisture commonly 
present in this region. 



APPLYING PLASTEE FOR EXTENSION. 



267 



The neglect of these little points often gives the patient and 
the surgeon a good deal of annoyance. 

The instrument now being in position, the nice adjustment, 
which is to regulate the amount of extension, is made by means 
of the key. In this way the exact amount of extension necessary 




Fig. 16.7 



Fig. 163. 



Fig. 



can be applied, and is to be regulated by the following rule : 
Apply sufficient extension so that when a sharp, sudden concus- 
sion is made from the knee, or the heel when the limb is straight, 
it will cause no pain whatever ; that is all the extension required, 
and your patient's face is to be your guide in deciding when a 
sufficient amount has been obtained. More extension than this 
may give rise to an obstruction to the circulation, and do an infi- 
nite amount of harm. 

At night, and at such other times as deemed necessary, the 
patient is placed in bed, and the bed-extension adjusted before the 
splint is removed or shortened. So, also, whenever the patient 
wishes to get up you are to apply the instrument and lengthen 



268 



DISEASES OF THE HIP-JOINT. 



the shaft, that is, make extension, hefore the bed-extension is re- 
moved. 

If the patient is a small child, like this one before you, he 
may be permitted to wear the splint without using crutches. (See 
Fig. 170.) If the patient be of much size, crutches will be neces- 




Fig. 170. 

sary, for the plaster is only intended to retain the instrument in 
position and maintain sufficient extension to relieve the joint from 
all pressure, but not to support the weight of the body if the 
child is heavy. 

If, after the application of the splint, the patient suffers 
pain, it is evidence that the splint has not been properly adjusted, 
and it should be carefully examined, for it may be that the plas- 
ters have yielded somewhat so as to permit pressure upon the 
joint. If so, it can be easily remedied by giving a little more 
extension with the key. 

Now the patient is in a condition to receive the constitutional 
treatment so necessary in his case, which consists of beef, milk, 
bread-and-butter, etc., but, above all, plenty of sunlight and pure 
air. 

The apparently trivial points which I wish you especially to 
remember (for they are really important, and neglect to observe 



LONG SPLINT. 



269 



them has many times brought the instrument into disrepute) are 
the following : 

1. Always shorten the shaft before applying or removing the 
instrument. 2. See that the jaws are tightly buckled, so that 
they will not be crowded down, and press upon the condyles. 3. 
Do not, as I have seen done, tuck the tape between the roller and 
the buckle. 4. Do not buckle the perineal band too tightly, for in 
that manner you may obstruct the femoral vessels, but make the 
extension with the key, which tightens the band by crowding it 
upward rather than by girdling the limb. There is a point 
with reference to the sound limb that must be mentioned ; when 
the long splint is worn, have the sole of the boot or shoe worn 




Fig. 171. 



upon that side made extra thick, for the purpose of equalizing 
the length of the two limbs. 

Finally, it will be noticed that the knee is left to move as 
freely as it may. I can see no propriety whatever in restraining 
the movements of this joint in cases of hip-joint disease in its 



270 DISEASES OF THE HIP-JOINT. 

earlier stages, when the thigh is long enough to permit the appli- 
cation of the short splint. There may be other circumstances 
when it becomes necessary to give the knee support, etc., where 
the long splint should be employed and the movements of the 
knee-joint restrained. But, all such considerations being set 
aside, there is no reason why unrestricted motion at the knee 
may not be permitted. 

It was designed that the motions of the joints should be free, 
and no harm will attend this freedom of motion, unless the joint 
itself becomes the seat of disease ; but, on the contrary, restraint 
will give rise to more or less anchylosis and deformity. 

I resort to the use of this short splint as early as possible, in 
order that the patient may have the benefit of exercise in the 
open air. It sometimes happens that it cannot be applied by rea- 
son of abscesses, or some other cause. In such cases the bed 
with extension may be arranged upon some light wagon or 
wheel-chair, so that the patient can be carried out-of-doors, and 
placed as far as possible under the influence of good hygienic 
conditions. 

In such cases, however, I more commonly employ the long 
splint, which is a modification of that devised by Dr. C. F. Tay- 
lor, of this city. 

This splint differs from the short one described above, in the 
following particulars : 

In the first place it extends the entire length of the limb, 
receives the weight of the body at a cross-bar under the foot, and 
has two perineal straps with an iron girdle nearly encircling the 
pelvis. The long bar, reaching from the pelvis to the bottom of 
the foot, is hollow, and has another running inside of it furnished 
with a ratchet and key {see Fig. 171), by which we make exten- 
sion, and is locked in the same way as upon the short splint. 
The cross-bar at the bottom of the instrument is covered with 
leather, and a "strong leathern strap, J", passes beneath two iron 
rods just above the cross-bar, to which are attached the tabs from 
the adhesive plaster upon the leg. This completes the attach- 
ments at the lower portion of the instrument for making exten- 
sion. 

There is also a knee-pad, G, which is attached to the bar run- 
ning along the outer side of the limb in such a manner that it 
can be moved up and down to any point desired. 



LONG SPLINT. 271 

An additional means for applying elastic force is attached to 
the posterior part of the instrument which is to be used in cases 
when the thigh is strongly flexed. It consists of an elastic band 
which is attached above the knee, runs along the back of the 
thigh, and is secured to the posterior portion of the pelvis-belt. 
This band can be made tighter as occasion may require, for the 
purpose of extending the limb, and should be elastic, for the pur- 
pose of keeping up a constant tractile force, and at the same time 
allowing flexion when the patient wishes to sit down. A fixed 
or leather strap, as used by Taylor, prevents any motion whatever 
at the hip, and simply anchyloses the joint. 

This instrument has been essentially improved by Mr. Reyn- 
ders, by the following additions : 

The improved parts are where the long rod is attached to the 
pelvic band. The long rod is attached at A to a round revolving 
plate, B, which is fastened to the pelvic band. When the plate 
B is revolved (partly) the long rod moves forward and backward. 
From the point A, the long rod moves from and toward the 
other leg, as shown by the dotted lines toward L. C is a screw 
terminating at D in a small square stem of steel, fitting to a 
key. This screw turns in and out of the revolving plate B, and 
has at the end of its thread a little knob, which is a little larger 
than the perforation at the upper end of the long rod, so that, 
when the key is applied at D and turned, the screw C will force 
the long rod in the direction toward L. In this manner abduc- 
tion is made. At F the long rod is divided into two parts ; the 
lower part holds an endless screw transversely, which is worked 
by a key, and rotation thus produced. {See Fig. 171.) 

As a matter of comfort to patients, these long splints are also 
used with joints at the knee, in slight cases of disease, or when 
convalescence has definitely set in. These joints are sometimes 
made with coiled springs at the knee, by which, when the leg is 
bent backward and the power relaxed, it will spring forward in- 
voluntarily. 

The limb is prepared for the long splint in the following 
manner : 

Cut two strips of strong moleskin adhesive plaster from two 
to four inches wide, according to the size of the limb, and long 
enough to reach its entire length, and divide the upper extremity 
of the plaster into narrower strips for a distance of two or three 



272 DISEASES OF THE HIP-JOINT. 

inches. Pieces of strong webbing, one or two inches in length, 
with buckles attached, are sewed to the lower extremities of the 
plasters. These plasters are then placed on either side of the leg 
in snch a manner as to leave the buckles a little above the ankle- 
joint, and then so secured by a snugly-adjusted roller as to leave 
the tabs with the buckles attached hanging loose. The roller is 
then carried up over the knee, and as far up the thigh as can be 
done with convenience, when the upper split ends of the strips 
of plaster are reversed and braided in with the roller as it re- 
turns down the thigh, securing it smoothly. The stocking is 
then pulled up on the foot, holes having been cut on either side 
for the buckles to pass through, and the shoe applied with holes 
cut through it in the same way. 

The limb now being prepared, the instrument is placed on its 
outer side, and the cross-bar at the bottom brought in front of the 
heel of the shoe, and securely buckled to the tabs above described. 
The pelvis-belt is next brought around the hips, and secured by 
the buckle upon the opposite side, and the perineal bands are 
next attached as firmly as may be. The knee-pad band is then 
slipped up or down until it is made to rest opposite the knee, 
when it is passed around the leg and buckled. Extension is now 
made with the key upon the ratchet until free compression is borne 
without pain, and the patient can walk without cane or crutch. 
{See Fig. 195.) 

If the limb is adducted, the abducting screw can be used, daily 
increasing the tension for the purpose of abducting the limb. 

If the limb be strongly inverted, the eversion-screw can be used, 
the force being gradually applied for the purpose of rotating the 
foot outward ; and, if the thigh is strongly flexed, the force exert-, 
ed by the elastic band upon the posterior part of the splint can 
be applied for the purpose of producing extension. 

In case you are not able to obtain either a short or long splint, 
it is possible to treat the case successfully by means of the bed- 
extension alone. Another method is, in addition to the bed-ex- 
tension, to make extension by increasing the weight of the shoe 
worn upon the foot of the affected limb, and permitting the 
patient to go about on crutches. This can be done by running 
lead into the sole of the shoe. In such a case you will be obliged 
to increase the length of the sound leg by making the sole of the 
shoe considerably thicker. In this manner the patient can be up 



TREATMENT OF FIRST STAGE. 273 

and around a portion of the time, sufficient, at least, to relieve him 
from the bad influence of continued confinement in bed. By 
using the wheel-crutch, manufactured by Darrach & Co., and the 
weight in the bottom of the shoe, in addition to the bed-extension, 
the patient can be made very comfortable indeed. 

These are methods which may be resorted to when proper 
splints cannot be obtained. 



LECTUEE XXII. 

DISEASES OF THE JOINTS. MORBUS COXAEIUS (CONTINUED). 

Treatment (continued.) — Treatment for the First Stage. — Treatment for the Second 
Stage. — Treatment for the Third Stage. — Case illustrating Treatment of Ad- 
vanced Hip-Disease without Complete Exsection. — Indications for Exsection. 

Gentlemen: At my last lecture we studied the principles 
which should guide us in the local treatment of hip-disease, and 
I also gave you a description of the apparatus and the manner of 
their application, by means of which you are to carry them into 
practical operation. 

Now, for the sake of clearness, let us return, and to-day con- 
sider separately the treatment to be adopted in each stage. 

What, then, is the treatment for the first stage f 

Local depletion by means of leeches or cups is often neces- 
sary. The bowels should be kept free. 

Such constitutional remedies are to be employed as may be 
requisite in each particular case. 

Such general support should be given as the system seems to 
demand. Issues in this stage of the disease are worse than use- 
less, and do harm instead of good. The only good they ever 
have effected can be explained by the fact that they made the 
parts so painful the patient was compelled to keep more quiet 
than he otherwise would have done. The occasional application 
of iodine or a blister may be of some service ; but in a majority of 
cases I have found the application of leeches and ice to be much 
more beneficial. The most important of all the means to be em- 
18 



274 DISEASES OF THE HIP-JOINT. 

ployed, and the one upon which all prospect of success depends, 
is rest of the joint and perfect freedom from pressure of the in- 
flamed articular surfaces. If left to itself, the rest which is so 
essential to the joint is procured by the firm muscular contraction 
which prevents motion, and this is so perfect, in many instances, 
as to assume the appearance of genuine bony anchylosis. But 
such constant muscular contraction exhausts the nervous system, 
presses the head of the femur against the acetabulum, and pro- 
duces absorption of both. 

I therefore at once resort to artificial means for overcoming 
the muscular contraction, thereby removing pressure from the 
parts involved in the disease. For this purpose I most commonly 
employ the extension by means of weight and pulley, while in 
bed, and the short splint, unless, for certain reasons, the long 
splint is preferable, while the patient is taking exercise. This 
apparatus has been already described, with the mode of applica- 
tion, in our last lecture. 

If there is a great deal of tenderness around the joint, and 
other evidences of inflammatory action are present, it is alto- 
gether better to first place the patient in bed, and apply the 
simple extension by weight and pulley, and let him remain in 
this position until the inflammatory action has- to a considerable 
extent subsided. This may be facilitated by the application of 
leeches or ice, or both, as already indicated, and the administra- 
tion of such remedies as the case may demand. 

When the inflammatory action has been subdued, the short or 
long splint may be applied, and the patient permitted to go 
about. 

If the patient is uneasy, restless, irritable, and does not bear 
the extension apparatus well, he may with propriety be placed in 
the wire cuirass (see Fig. 190), or other fixed apparatus. But I 
must again warn you of the danger of permitting the patient to 
wear such fixed dressings too long. If employed at all, they must 
be frequently removed, and passive motion employed, else anchy- 
losis, more or less complete, will take place, and the last state of 
the patient may be worse than the first. 

Again, the deformity, even in this stage, may be so great as 
not to permit of the immediate application of the splint. In such 
cases you must place the patient in bed, and apply extension 
first in the line of deformity, and then gradually, day by day, 



TREATMENT OF SECOND STAGE. 275 

bring the limb toward the normal position, and, when this has 
been nearly or quite reached, the splint may be adjusted and the 
patient permitted to get up. Sometimes it happens that the 
muscles have become so firmly contracted that they will require 
subcutaneous section before the limb can be brought into its 
proper position. 

It should be your aim to bring the limb as soon as possible 
into a proper position, so that the splint can be used, for, when it 
is applied, pressure can be removed from the articular surfaces, 
motion permitted, and the patient is in a condition to obtain all 
the benefits of sunlight and fresh air. Even if the splint cannot be 
worn more than two, three, or four hours each day, the change of 
position, the moderate exercise, the sunlight and fresh air which 
the patient is able to obtain without endangering the diseased 
joint, will be of more benefit to him than all the medicine in the 
world. 

In very many cases the bed-extension and the splint can be 
applied at once ; one to be used at night and stormy days, and the 
other to be worn when the weather is pleasant, so as to permit 
the patient to be out-of-doors. 

Change of air, from the sea to the interior, and vice versa, and 
from low valleys to the mountains, and from the mountains to the 
sea, is very essential. 

Next, what is the treatment for the second stage f 

The treatment of this stage necessarily differs according to the 
condition of the joint and the character and quantity of its con-, 
tents. If the disease is simply subacute in character, the joint not 
disintegrated, the effusion small in quantity (recognized by the 
small degree of malposition and limited motion), slight but per- 
manent extension comes first. This can be accomplished by the 
extension apparatus already described. Extension is employed 
for the purpose of counteracting the morbid contraction of the 
muscles, and to relieve the pressure upon the articular surfaces of 
the joint, and is to be persisted in imtil the more prominent in- 
flammatory symptoms have subsided. Here, again, the extension 
must always be made in the line of the deformity, and gradually 
changed until the limb is brought as nearly as possible into the 
normal position. 

The continuous extension in bed, preparatory to the applica- 
tion of the splint, will be more frequently required in this than in 



276 DISEASES OF THE HIP-JOINT. 

the first stage, and, when the normal position of the limb has been 
reached as nearly as possible, the instrnment may be applied, and 
the patient allowed to take out-door exercise. If the inflammatory 
action is somewhat active, repeated but moderate depletion by 
means of leeches or cups, pressure by means of adhesive straps, 
and a mild mercurial treatment both internally and externally, 
will assist in subduing it, and promote the absorption of the fluid. 
This treatment will be applicable in a majority of cases, but there 
are those in which the inflammation is so violent, and the pain 
upon the slightest motion so intense, that absolute rest will be re- 
quired for a time. For such cases, the wire cuirass is almost in- 
dispensable, especially in small children. If the inflammation is 
very acute, indicated by local pain, heat, and general constitu- 
tional disturbance, and the patient has a vigorous constitution, 
the cause being clearly traumatic, and suppuration not yet begun, 
I deem an energetic antiphlogistic treatment to be the safest 
method of subduing the inflammation. 

In such cases, the effusion may act as a new excitant for the 
perpetuation of the inflammation ; consequently, if the joint be- 
comes distended beyond endurance, causing great local trouble, 
and reflects detrimentally upon the general system, the prompt 
removal of the fluid becomes absolutely necessary. This opera- 
tion never fails to give immediate relief from all the more 
prominent symptoms, and restore rest and comfort to the pa- 
tient. In fact, it is the only anodyne that will perfectly relieve 
the pain under these circumstances. By removing this intolerable 
pressure we simply imitate Nature, who accomplishes the same 
thing by spontaneous rupture of the capsule. 

The accumulated fluid in such cases can be safely removed by 
means of the aspirator. In case you have not an aspirator at hand, 
a small trocar may be used with a canula, to which is attached an 
air-tight syringe, that acts upon the same principle as the stomach- 
pump. A small trocar and canula may be employed, but much 
greater care is necessary in its use, lest air should enter the cavity 
and become imprisoned. The operation by means of the trocar 
and canula is to be performed in the following manner: The 
patient should be placed upon the healthy side, and an ansesthetic 
administered to obviate the pain caused by moving the limb in the 
manner necessary to expel the fluid. 

The most favorable place for puncture is immediately behind 



PUXCTUEING OF HIP-JOIXT. 277 

the middle line of the femur, and above the large trochanter, close 
to the superior margin of the tendon of the gluteus maximus mus- 
cle. At this point we can enter the hip-joint just above and in 
front of the digital fossa. The canula should not enter the joint, 
perhaps more than one-eighth or one sixteenth of an inch. This 
is particularly to be borne in mind, when it becomes necessary 
to use an ordinary trocar and canula, for the moment the capsule 
has been punctured the trocar is to be withdrawn, and the affected 
limb steadily inverted, adducted, and rotated over and across the 
opposite limb for the purpose of completely removing the fluid 
from the joint. This position should be retained until the canula 
is withdrawn, the wound carefully closed by adhesive plaster, and 
the joint carefully surrounded by compress and long adhesive 
straps, which will exercise pressure and prevent air from entering 
the vacuum that will be created when the limb is returned to the 
straight position. The patient should then be secured in some 
apparatus — the wire cuirass (Fig. 169) is most convenient — which 
will prevent the possibility of motion. Besides the rest, a low diet 
and a moderate antiphlogistic treatment may be necessary for a 
few days. When the fluid has been removed by the aspirator, as 
in the manner just described, reaccumulation very rarely takes 
place ; but, if it does, the operation may be repeated with safety. 

If the fluid removed from the joint is purulent (which might 
have been ascertained previous to the operation, by a careful 
analysis of the constitutional symptoms), the question arises 
whether the pus is simply the product of synovitis, or whether 
it is associated with ulceration of the cartilage and caries of the 
bone. 

With very few exceptions, when there is ulceration of cartilage 
and bone, we find more or less crepitus, which can be easily rec- 
ognized by rotating the affected limb after the fluid has been 
withdrawn. In the absence of crepitus, especially if this disease 
is of but short duration, we are justified in presuming that the 
case is simply one of suppurative synovitis; hence we may give 
the patient a chance of recovery without any further operative 
procedure. 

If, however, we can satisfy ourselves that the articular surfaces 
have become ulcerated, the cartilages disintegrated, and the bones 
eroded, which is indicated by the presence of a crepitus peculiar 
to itself and altogether different from the crepitus of healthy 



278 DISEASES OF THE HIP-JOINT. 

bone, we consider exsection of the joint not only justifiable, but in 
most instances absolutely essential. 

When other joints have been found in a similar condition, 
more especially where the disintegration has gone on only to a 
limited extent, I have freely opened them, passed setons through 
them, injected them with iodine, and thereby obtained satisfactory 
results. 

In many instances I have had perfect recovery, with free mo-, 
tion. But the principle of incision seems not to be applicable to the 
hip-joint, since its conformation, its deeply-seated situation, and 
investment with soft parts, obstruct the free exit of the discharge. 

In fact, the hip-joint can hardly be said to be freely opened 
without removing the head of the femur, which fills it completely. 

Finally, what is the treatment for the third stage f 

In this stage there is invariably rupture of the capsule or per- 
foration of the acetabulum. Rupture of the capsule may take 
place from over-distention with the products of inflammation, 
such as serum and lymph ; or it may follow ulceration of the car- 
tilages and bones, in which case the contents will be purulent. 
These two conditions differ from each other very widely, for 
in the former the contents of the capsule escape into the cellu- 
lar tissue, thereby relieving the pressure within the joint, conse- 
quently the most prominent symptoms, and are finally removed by 
the absorbents or discharged. Inflammatory adhesions will fre- 
quently form about the joint, and the limb will be left in mal- 
position, but a spontaneous cure may be effected. Such cases are 
by no means rare, and it is this fact, probably, that has led many 
surgeons to rely upon the simple efforts of Nature, more than 
upon surgical art, to effect a cure. Nor do I propose any active 
interference; but, on the contrary, I only suggest that Nature 
should be assisted by mechanical appliances in her efforts to bring 
about thisv spontaneous cure. The object of such appliances is 
merely to relieve the joint from pressure, by permanently ex- 
tending the morbidly-contracted muscles, and at the same time 
securing its perfect mobility, together with a normal position of 
the extremity. When the cure has been effected by the unaided 
efforts of Nature, it is invariably accompanied by deformity, and 
that deformity, in a large number of cases, is dependent upon 
false or fibrous anchylosis. This result was formerly. considered 
the most satisfactory termination that could be expected, but even 



PAETIAL ANCHYLOSIS, 279 

this has been brought within the reach of surgical art, and is 
susceptible of perfect relief ; for division of the contracted mus- 
cles implicated in the deformity, and breaking up the adhesions 
by force, while the patient is under the influence of an anaes- 
thetic, followed by proper orthopedic treatment, have in numer- 
ous instances removed the deformity, and restored motion and 
usefulness to the limb. {See Case, page 256.) 

"When, however, ulceration of the cartilages and bone is pres- 
ent and is accompanied by purulent effusion, we have a very dif- 
ferent condition of affairs to deal with, consequently our surgical 
procedure must vary accordingly. In this condition spontaneous 
cures are extremely rare, and, if we deduct from them the cases 
of periostitis that have been mistaken for caries affecting the hip- 
joint, the number will be still further reduced. Indeed, a care- 
ful examination of many cases, in my own practice and in the 
practice of others, has led me almost to doubt whether it ever 
occurs. We can hardly be surprised at this when we consider the 
many natural obstacles to a free discharge of the detritus, thereby 
almost invariably creating new disease in such tissues as it may 
come in contact with. It is in this manner that the disease is 
perpetuated, because of the inability of Nature to establish a suf- 
ficiently free opening for the removal of the parts already de- 
stroyed. Nature, unaided, has only one efficient method for cur- 
ing caries, and that is by gradual exfoliation and removal of the 
dead bone, establishing healthy granulations in the sound por- 
tion, thereby substituting for the part removed fibrous and often- 
times ossifying structure. This process is extremely slow, and 
may require even years for the removal of a comparatively small 
fragment of bone. In this morbid specimen you see here, kindly 
furnished me by Dr. Janeway, the disease had been in existence 
eighteen years, and yet, as you see, the removal of the dead bone 
had not been quite completed. But, if these patients do spon- 
taneously recover, after advancing thus far in the disease, deform- 
ity is always present, unless the very greatest care is exercised 
in retaining the limb in a proper position while recovery is tak- 
ing place. 

It is from Nature's method, however, that we are to deduce 
the principles that are to govern us in the treatment of these 
cases. These principles have long been recognized and practically 
adopted by the profession, for exsection of other joints for the 



280 DISEASES OF THE HIP-JOINT. 

cure of caries and necrosis is an operation of daily occurrence. 
But, strange to say, caries affecting the hip- joint has, nntil within 
a few years, been excluded from the list of cases to be benefited 
by this operation, and by many surgeons the operation of exsec- 
tion is discountenanced at the present time. 

The question now arises, How are we to determine whether in 
a given case the operation of exsection should be performed % 

If you find that the discharge is diminishing, the general 
health of the patient improving, and that the limb can be brought 
into a position in which it will eventually be of service, it is better 
to permit the case to go on, aud allow the cure to be completed 
by the gradual exfoliation and discharge of dead bone, according 
to Nature's method, than to resort to the operation. 

In these cases, however, you can do a great deal to assist 
Nature by dilating the sinuses leading to the dead bone with 
sponge-tents, and, if necessary, making free openings in various 
directions, and inserting drainage-tubes of India-rubber or oakum 
setons, thereby facilitating the ready and complete exit of the 
discharge. 

This was done in the case you now see before you, and, by 
those who saw the case previous to treatment, the result can be 
readily appreciated. 

Case. Hip-Joint Disease of Eleven Years' Standing ; Exces- 
sive Suppurationj Exfoliation of Numerous Pieces of Bone ; 
Great Distortion and Fibrous Adhesions / Numerous Sinuses 
still discharging ; Tenotomy ; Forcible Improvement of Position ; 
Sinuses dilated and Dead Bone removed; India-rubber Tubes 
drawn through the limb from Side to Side ; Extension, Abduc- 
tion, and Rotation-Splint ; Recovery with Moderate Amount of 
Motion. — Nellie A., aged thirteen, was brought to me at Belle- 
vue Hospital, December, 1873, in the condition seen in Fig. 172. 
The right limb was firmly adducted across the left thigh, and 
fixed by fibrous adhesions ; eleven sinuses in different parts of the 
thigh led to necrosed bone, which was detected by the flexible 
probe (the sinuses being tortuous, an ordinary probe was useless 
in the examination) ; a deep cicatrix extended from the crest of 
the ilium down through the groin and back upon the outer por- 
tion of the thigh, very nearly encircling the limb ; another hard- 
ened cicatrix passed from the anterior superior spinous process of 
the ilium down below the trochanter major, and then curved in a 



CASE. 



281 



V-shape back to the outer portion of the thigh, meeting the first 
cicatrix described ; in these cicatrices there were various sinuses 
through which the probe could be passed in different directions. 




Ftg. 172. 



The mother stated that, when the child was two years of age, 
she fell down-stairs, striking upon her right hip, which resulted in 
a few months in a severe inflammation of that joint, ending in 
abscesses, which have been discharging more or less for the last 
ten years. 

During the first year of her suffering, the limb was apparently 
longer, and turned outward ; but, after the large abscess formed 
on the outer part of her hip, the leg turned inward and was 
shorter. She was much more free from pain after this than she 
was during the commencement of the disease, but she became very 
much emaciated and exhausted from the excessive discharge. All 
kinds of internal medication had been resorted to, but no efforts 
had been made to prevent the distortion and deformity. 

As she was unable to walk in such a condition, she was sent 
to me for the purpose of having exsection of the hip-joint per- 
formed. 

Upon carefully examining the case, I found that Nature had, 
during these eleven years, nearly succeeded in removing all the 
dead bone, and, as there was so much deposit around the parts as 



282 DISEASES OF TEE HIP-JOINT. 

to render exsection difficult, if not. dangerous, I determined to 
dilate the sinuses, and thus aid Nature in the removal of the re- 
maining dead bone, and, by tenotomy and section of the contracted 
fascia, endeavor, by force, to improve her position, rather than 
take the risk of performing exsection. This operation was per- 
formed at the time before the class, the limb forcibly abducted 
and extended, and secured in the normal position by making a 
long splint, extending from the axilla to the foot, with a cross- 
piece, some three feet long, at the bottom. This splint was 
secured to her well side, by bandages, the foot being firmly placed 
against the cross-piece. A pulley was placed at the end of the 
cross-piece, over which the cord from the adhesive plasters upon 
her diseased leg was run, and a six or eight pound weight was 
attached. This weight was increased or diminished according to 
her feelings, thus keeping up constant extending and abducting 
forces. The hip was enveloped in cloths wet with cold water ; 
but, finding that these gave great pain, large hot poultices were 
substituted for them, which afforded much relief. The sinuses 
were dilated with sponge-tents. 

In a few days several of the sinuses had become so much en- 
larged that small pieces of bone were readily picked out with the 
forceps, and three weeks after the first operation a large flexible 
probe was passed from the outer portion of the thigh, about an inch 
above the trochanter major, down through the limb, making its 
exit through one of the sinuses near the perinseum. A perforated 
India-rubber tube was threaded through the eye of the probe, and 
drawn through this canal, and is still worn (as seen in Fig. 173), 
although there is no occasion for it, the discharge having long 
since ceased ; but the girl having derived so much benefit from 
its use, insists upon still wearing it — like an ear-ring, more for 
ornament than use. Within a few months after this tube was 
passed through the limb, all the other sinuses gradually closed, 
and have remained so. 

Four months from the time of the tenotomy and Irisement- 
force, I applied to her one of my long splints, with abducting 
and rotating screws, modified in such a manner as to be slipped 
into the sole of her shoe, like a spur in a gentleman's boot, by 
which means the necessity of applying adhesive plaster to the 
limb was avoided. It also had a joint, at the knee, capable of 
permitting flexion in the sitting posture, but becoming stiff in 



CASE. 



283 



the erect position, and with it applied, and the sole and heel of 
the shoe elongated to match the opposite leg, she is enabled to 
walk without cane or crutch, as seen in Fig. 1 73, and is perfectly 
healthy. 

This patient was last seen December 1, 1875, when the photo- 
graph from which Fig. 174: was cut, was taken. 

There is no discharge from any of the sinuses, and no neces- 
sity for wearing the drainage-tube. Has grown very much and 





Fig. 173. 



Fig. 174. 



is in perfect health ; has some motion at hip-joint ; can flex, 
abduct, and extend her leg to a considerable degree. 

If, notwithstanding this treatment, the discharge does not di- 
minish, but rather increases ; if symptoms of progressive caries de- 
velop in the part ; if the disease, instead of improving, progresses in 
spite of all your efforts to subdue it ; the general health of the pa- 
tient is daily becoming undermined, and there are no symptoms 
indicating repair, the only justifiable treatment left for the surgeon 
is exsection of the joint. Nature cures these cases by exsection, 
but the patient very frequently dies before the operation is com- 
pleted, in consequence of exhaustion produced by the long-contin- 



284: DISEASES OF THE HIP-JOINT. 

ued discharge. It is for this reason that the operation is justifiable. 
More can be done in half an hour with the knife and saw, in the 
way of removing dead bone, than can be done by Nature in 
many years ; hence I urge that it is the duty of the surgeon to 
exsect the joint, thereby removing the patient from the dangers 
attending long-continued suppuration. It would seem, to an un- 
biased mind, that the same therapeutical indications might be 
applicable to the hip- joint, so far as exsection goes, as to any 
other joint. In fact, it is my firm conviction that caries of the 
hip-joint, by reason of the impending danger of perforation of 
the acetabulum, requires more prompt and decided surgical inter- 
ference than when it manifests itself in any other joint of the 
body. The operation is not only justifiable, but imperatively 
demanded. No less an authority than Prof. Syme has made the 
assertion that, " if the acetabulum be carious, the patient must 
die." We can therefore lose nothing by the operation if this be 
true, but will, on the contrary, invariably procure comfort for 
the patient. But the assertion is not true, for in the majority of 
cases, as shown by my own statistical table, the patients have had 
their lives saved. Nor is that all : we not only save the life of 
the patient by the operation, but we also restore form and motion 
to the limb. Of course you must not expect that every case of 
exsection will prove successful. In one case, the disease may be 
so associated with constitutional vitiation that a mere local opera- 
tion will not eradicate it. In another case destructive processes 
may have gone on to such an extent as to preclude the possibility 
of removing all the diseased tissues. 

In all such cases the disease will probably proceed to a 
fatal termination. But when the disease is chiefly local, the con- 
stitution not yet undermined, and its extent so limited as to 
admit of its entire removal by the knife, saw, and gouge, and 
when we can have the advantage of proper air and diet, I am 
certain that this operation, if performed at the proper time, offers 
the best possible chance for recovery. 

It is now twenty years since I performed the first successful 
exsection of the hip-joint in this country. And at that time the 
operation was very severely censured by nearly the entire pro- 
fession. But the numerons cases in which perfect success has 
been obtained have proved its feasibility, and it is now quite 
generally considered as justifiable. From this I now feel like 



HISTORY OF EXSECTION. 285 

making the prediction that by the time the entire profession has 
accepted it as a justifiable operation, surgeons will know sufficient 
concerning hip-joint disease and its treatment to render the 
operation entirely unnecessary ; for a thorough knowledge of 
its pathology, etiology, and very earliest symptoms, will lead them 
to such an early recognition of the disease as will enable them to 
treat it in a manner that will- obviate the necessity of exsection. 
At present, however, we are obliged to perform the operation in 
those cases where proper treatment in the earlier stages has been 
neglected, and must therefore study the method in which it should 
be done. To this subject we shall turn our attention at the next 
lecture. 



LECTURE XXIII. 

DISEASES OF THE JOINTS. — MORBUS COXAKIUS (CONCLUDED). 

Treatment (continued).— Exsection. — History of the Operation. — The Operation de- 
scribed. — Mode of dressing the Limb after the Operation has been performed. — 
After-Treatment. — Tables of Exsections appended. 

Gentlemen : The history of Exsection, for the relief of hip- 
joint disease, lies within the present century. 

The possibility of removal of the upper extremity of the fe. 
mur was first suggested by Mr. Charles White, in 1769 ; but the 
first surgeon to attempt the operation in morbus coxarius was 
Schmalz, in 1816. In his case the head of the bone was found 
loose, and simply required removal. The cases of Sclitching, 1 
Hoffmann, Batchelder, and Klinger, were similar to that of 
Schmalz. 

In 1818 Anthony White performed his celebrated operation, 
which has generally been referred to as the first successful exsec- 
tion of the head of the femur in morbus coxarius. 

From 1818 until 1S45, it appears that the operation was per- 
formed by only two surgeons, namely : Hewson, of Dublin, in 

1 Sclitching's case was one of exfoliation and not exsection, and is the first case of 
this description ever reported, as far as I can discover. It occurred in 1Y20. — See. 
"Philosophical Transactions " for 1*742. 



286 DISEASES OF THE HIP-JOINT. 

1828, and Textor, Sr., who operated three times prior to 1845 — 
once in 1834, once in 1838, and again in 1839 ; all terminating 
unsuccessfully. Textor operated again in 1845, and the case ter- 
minated successfully, the man subsequently obtaining his living 
as a peddler. 

Mr. Ferguson has operated five times, and with uniform suc- 
cess. One of his patients died two years after the operation, " of 
enlargement of the liver, after having experienced great relief 
from the proceeding." 

Mr. Ferguson states •(" Medico-Chirurgical Transactions," vol. 
xxviii.) that he has learned that Mr. Brodie performed this opera- 
tion, and " the patient died within a few days after, the direct 
effect of that proceeding ; " but Mr. Henry Smith, writing in 
1848 (London Lancet), remarks that he has not been able to 
" obtain any accurate information respecting the correctness of 
this assertion." There is no doubt, however, that this surgeon 
did exsect the head of the femur at St. George's Hospital, about 
the year 1836, but, under what circumstances, and with what 
result, I have been unable to ascertain. 

Carmichael, of Dublin, it has been supposed, performed this 
operation in 1820 ; but it is more than probable that the case has 
been confounded with an exarticulation for medullary sarcoma, 
which he made at that time. 

In this country the operation attracted but little attention, 
until I published my first case in the New York Journal of 
Medicine for January, 1855. That was the first time the opera- 
tion had been successful in this country. 

Dr. Bigelow, of Boston, had performed the operation about a 
year before, but had not published the case. Dr. Bigelow's case 
terminated fatally on the twelfth day after the operation. 

A case is reported in the New York Medico-Surgical Reporter, 
January 10, 1846, in which Dr. S. P. Batchelder, of this city, 
removed the head of the femur in 1845, under the following cir- 
cumstances : A young man had been kicked upon his hip by a 
horse four or five years before. Severe symptoms followed; 
fistulous openings formed, and pus was freely discharged. Fi- 
nally, dead bone was detected by the probe. The fistula was 
dilated with sponge-tents, and the dead bone removed by the 
forceps, which proved to be the head of the femur. After the 
operation the patient improved rapidly, and eventually recovered. 



OPERATION OF EXSECTION". 287 

This could not be called a case of exsection, and therefore has not 
been included. I have heard that Dr. Parkman, of Boston, 
exsected this bone in 1853, but have been unable to obtain any 
particulars of the case. This leaves my operation in March, 1854, 
as the first in this country that terminated successfully. I have 
now performed the operation in fifty-nine cases, and the results 
may be seen in the tables appended to this chapter. 

So much, gentlemen, for the history of the operation, and I 
will now show you practically how to perform it, and explain the 
various steps in the operation, and the mode of dressing the pa- 
tient after it is performed, as we proceed. 

This little patient you see before you was brought to the 
hospital some months since in a dying condition, having been 
found in a garret in Baxter Street. Her father had been dead 
for some time, and her mother was in a lunatic asylum. She had 
no friends or relations that could give any information of her 
previous condition, the cause of her disease, or how long it had 
existed. 

At the time of her admission she was so nearly dead from ex- 
haustion that an operation was not deemed justifiable. 

Her health has greatly improved since she has been in the 




Fig. 1T5. 



hospital, but she is still in a most wretched condition, as seen in 
Fig. 175, from a photograph by Mr. Mason. This photograph 
had to be taken in the ward, as it was impossible to move her to 
the gallery, and therefore the picture is very indistinct. 



288 DISEASES OF THE HIP-JOINT. 

She has laid in the position yon now see her nearly all the 
time since she has been in the hospital, and it is impossible to 
move her in any manner withont giving her the most intense 
pain. The thigh, as you see, is flexed, and strongly addncted 
across the opposite limb, and there are several sinnses through 
which the probe readily passes to necrosed bone. 

We will now proceed to the operation, which is performed in 
the following manner : Administer an ansesthetic, and then place 
the patient upon the sound side. Next select a strong knife, and 
drive it home to the bone at a point midway between the anterior 
inferior spinous process of the ilium and the top of the great tro- 
chanter ; then drawing it in a curved line over the ilium, keeping 
it firmly in contact with the bone, make an incision across to the 
top of the great trochanter, extending it not directly over the 
centre of the trochanter, but midway between the centre and its 
posterior border, and complete it by carrying the knife forward 
and inward, making the whole length of the incision from four to 
six or eight inches, according to the size of the thigh. In this 
manner a curved incision is made through all the soft parts down 
to the bone and through the periosteum. If you do not feel cer- 
tain that the periosteum has been divided over the femur by the 
first incision, carry the point of the knife along the same line a 
second, and, if need be, a third time. 

The first incision having been made, an assistant, by means of 
his fingers or retractors, draws the soft parts aside, and you come at 
once upon the great trochanter. Then, with a narrow, thick knife, 
make a second incision through the periosteum only, at right 
angles with the first, at a point an inch or an inch and a half 
below the top of the great trochanter, as the case may be, just 
opposite the lesser trochanter, or a little above it, and extend it as 
far as possible around the bone. Here, again, make sure that the 
periosteum is freely divided. Very often a thick involucrum will 
be present, and great care will be necessary in order to make the 
incision through the periosteum complete. Now, we have first a 
curved incision through the soft parts ; and, second, a T-shaped 
incision through the periosteum at the point indicated on the out- 
side of the femur, just above the lesser trochanter. At the junc- 
tion of the two incisions through the periosteum introduce the 
blade of the periosteal elevator {see Fig. 112), and gradually peel 
up the periosteum from either side, together with its membra- 



OPEEATION OF EXSECTION". 289 

nous attachments, until the digital fossa has been reached. At 
this point the rotators of the thigh are inserted, and the attach- 
ments are so firm that you will not be able to peel them off, but 
will be obliged to divide them with the knife. 

When dividing these insertions you should be very cautious 
and keep the knife close to the bone, making only a very small 
incision, as a branch of the internal circumflex artery lies very 
close to them, and, of course, must be carefully avoided. 1 

After the tendons have been divided, continue to elevate the 
periosteum upon either side as far as can be safely done without 
breaking it. You should aim to peel off the periosteum intact, 
and leave it as a perfect sheath after the bone has been removed, 
for the purpose of preventing any infiltration into the surround- 

1 The following note which I have received from Dr. J. A. Wyeth, describing the arte- 
rial distribution, I have deemed of such importance that I have added it as a foot-note : 
" The comparatively trifling amount of blood lost in an operation of such magnitude 
as the excision of the hip-joint, where there is no means of stopping the supply of 
blood to the part, has doubtless added very much to the remarkable success which 
has attended this operation in the hands of its author. The following synopsis of 
twenty dissections of the hip-joint, made with regard to the arterial distribution to this 
region, may serve to show the extreme nicety of execution requisite in order to avoid 
haemorrhage that would always be annoying, and in some instances dangerous. The 
arteries found distributing branches to this region were the gluteal, sciatic, obturator, 
external, and internal circumflex, and the superior perforating by anastomosis ; none 
of these approached the line of incision given by Prof. Sayre near enough to be 
divided before they broke up into branches of distribution too small to give rise to 
any noticeable haemorrhage, except one of the terminal branches of the internal cir- 
cumflex, sometimes mentioned as the trochanteric branch, but never described in con- 
nection with the surgical anatomy of this operation, to the writer's knowledge. In 
twenty dissections this artery was present in every case. In eighteen of these it came 
from the internal circumflex, passed between the quadratus femoris behind, and the 
obturator externus in front, and, turning toward the digital fossa, broke up into its 
terminal branches within from one-eighth to one-quarter of an inch of the insertion 
of the obturator externus into that fossa, anastomosing with the sciatic, gluteal, 
and external circumflex arteries. In two cases in which it failed to come from 
the internal circumflex, it was derived from the sciatic, and ran in the depression 
between the quadratus femoris and obturator externus to its usual distribution. 
This vessel varied in size from a crow's-quill down, oftener small than large, but 
in all cases of sufficient size at the distance from the fossa given above to interfere 
with the success of the operation if carelessly divided. As it is only at this point that 
the knife is used in the deeper structures (in cutting the tendons of the obturator ex- 
ternus out of its fossa) it behooves the young surgeon to guard against this danger by 
keeping the point of his knife 'well against the bone' as advised in the operation, and 
never to attempt to divide this tendon out of the fossa. The obturator externus 
muscle was occasionally observed to be inserted into the great trochanter, and not in. 
the digital fossa," 

19 



290 DISEASES OF THE HIP-JOINT. 

ing tissues ; and, also, to retain the muscular attachments for the 
future mobility of the joint. 

When the periosteum has been removed as far as can be safely 
done, the leg is to be slightly adducted, and the head of the femur 
lifted out from the acetabulum. 

In this manner that portion of the periosteum that could not 
be reached with the elevator is removed from the bone. 

Here, again, you should exercise great care and turn the bone 
out only just enough to permit the finger to go behind it for the 
purpose of guiding the saw in its removal ; for, if too free luxa- 
tion is made, you will displace the periosteum too extensively, 
and the consequence will be a subsequent exfoliation of the bone 
thus uncovered. You will, therefore, uncover only so much of 
the bone as you wish to remove by the saw. This leads me to 
speak of another precaution : never remove the bone with any- 
thing except a saw, a chain or a linger saw being most convenient. 
If you attempt to remove the bone with the bone-forceps, its ex- 
tremity will almost invariably be slivered and subsequent exfo- 
liation will take place. 

After the periosteum, then, has been removed as far as neces- 
sary, adduct the limb a trifle, depress the lower end of the femur 
to a slight extent, and lift the head of the bone out only just 
as far as is requisite to permit its removal with the saw, and then 
saw through the bone just above the trochanter minor. 

Never saw through the neck of the bone and leave the trochan- 
ter major, for the reason that, if this large portion of the bone 
is not removed, it will prevent a free discharge from the wound, 
and in that manner cause retention of pus. 

By removing the periosteum from the greater trochanter, you 
have carried all the muscular attachments with it, so that these 
are preserved ; hence there is no necessity for leaving the bone, 
and by removing it you have made a free opening for the dis- 
charge to flow through. 

It sometimes happens that the involucrum is so firm that the 
head of the bone cannot be lifted from its bed ; and in two cases 
I have seen fracture of the femur produced by the efforts at luxa- 
tion, preparatory to sawing off the bone. 

In such cases, or in any case where luxation cannot easily be 
effected, so as to permit the finger to pass around the bone, saw 
the bone off without attempting luxation, and then it can be 



OPERATION OF EXSECTIOX. 291 

lifted out by means of the forceps or the elevator. In such cases 
the operation is unusually tedious. 

If, after this portion of the bone has been removed, it is dis- 
covered that living bone has not been reached, the periosteum 
must be further removed, which can be done by luxating the 
femur a little more, slipping the bone through it, like a turkey's 
neck after his head has been cut off, until living bone has been 
reached, no matter whether it requires one, two, three, or five 
inches of the bone to be removed. 

I have seen one case in which nearly the entire shaft of the 
f enmr was removed and perfect recovery took place. In that case 
the operation was performed by Dr. Spencer, of "Watertown, Xew 
York. 

One great secret of success is to leave the periosteum entire. 
If the involucrum which usually surrounds the bone possesses 
sufficient vitality, it may be permitted to remain ; but if it is at all 
deficient in this respect, as indicated by its appearing like carious 
bone, it must be removed. 

iSText the acetabulum is to be examined, and, if found diseased, 
all the dead bone must be carefully removed ; if the acetabulum 
be perforated, this part of the operation must be performed with 
the greatest care, lest injury be done to the internal layer of pe- 
riosteum. The internal periosteum will be found peeled off, or 
lifted away, so as to make a kind of cavity behind the acetabu- 
lum ; and an exceedingly important point is to chip off all the 
edges around the perforation, down to the point where the inter- 
nal periosteum is reflected from the sound bone. This is one of 
the most delicate steps in the operation, to be able to remove all 
dead bone from the wall formed by the internal periosteum with 
out injuring or wounding it. In some cases, when the operation is 
completed, there will be nothing intervening between the finger 
of the operator and the rectum of the patient, except this internal 
layer of periosteum. 

Another important point is to thoroughly clean the original 
sinuses, carefully removing all portions of dead bone which may 
have lodged in their course during the progress of the disease, as 
well as the false membrane which lines them. 

If this precaution is neglected, much subsequent trouble in 
the way of continued discharge, and perhaps abscess, may arise. 

TThen all the dead bone has been removed, wash out the wound 



292 



DISEASES OF THE HIP-JOINT. 



thoroughly, fill it full of Peruvian balsain and stuff it with oakum. 
The extremities of the wound may be closed with stitches, but 
the central portion, which leads directly to the acetabulum, must 
be kept open in such a manner as to prevent the possibility of 
the discharge becoming retained. For this purpose use a plug 
of oakum. Never plug the wound with cotton or lint, for they 
will not permit a free discharge from the 
bottom. 

I have seen one case that terminated 
fatally, simply because the attending sur- 
geon used cotton, thereby giving rise to re- 
tention of the discharge., and fibres of cot- 
ton were found among the granulations 
and deep-seated tissues, months after the 
operation. 

Now the patient is ready to be placed 
in an apparatus which will secure absolute 
rest, and a proper position for a certain 
length of time. For this purpose, the most 
convenient instrument that can be em- 
ployed is what is known as the wire cui- 
rass. (See Fig. 176.) 

This instrument is a modification of 
Bonnet's grand cvppa/reil, and consists of a 
strong wire netting, well padded inside. 

The cuirass being properly prepared 
and well padded, the patient is laid in it 
so that the anus is opposite the opening, 
and free from any possibility of obstruc- 
tion, when the well leg is the first to be 
dressed. This is done by making the leg 
perfectly straight and screwing up the foot- 
rest until it is brought firmly against the 
heel of the patient, placing a pad between 
the foot and the rest to absorb the perspiration ; the instep is then 
well padded with cotton or a blanket, and a roller is carried firmly 
round it and the foot-rest, running up over the limb ; but before 
going over the knee a piece of pasteboard, or leather, or several 
pieces of folded paper, are placed over the leg, knee, and thigh, 
and the roller carried firmly over this extemporized splint for the 




Fig. 1 



OPEEATION OF EXSECTION. 293 

purpose of preventing the slightest bending of the knee, when 
the roller is carried up the entire length of the thigh, around the 
perinaeum and over the outer arm of the instrument, and several 
times hack through the perinaeum, and then across the pelvis, by 
which means the well limb is made a firm counter -extending 
force. 

Two strips of adhesive plaster, two to four inches in width, ac- 
cording to the size of the patient, are then placed upon either side 
of the operated limb, and secured with a nicely-adjusted roller over 
the foot and up the leg and thigh, as far as the abscesses on it or 
the wounds w T ill permit, being careful to leave a sufficient length 
of the plasters at the lower extremity free, for the purpose of 
applying them to the foot-rest w T here extension is made. The 
foot-rest is then screwed up to meet the heel of the shortened 
limb, and these strips of adhesive plaster are brought down 
around the foot-rest and securely fastened. The foot-rest is then 
extended by the screw, slowly and gradually, at times waiting 
a few moments for the muscles to yield, which have been so 
long contracted, until the limb is brought down to its full ex- 
tent. It sometimes happens that, from long contraction of the 
adductors and the tensor vaginae femoris, subcutaneous section 
of those tendons and fascia will be requisite before the limb 
can be brought to its proper position, even after the head of the 
femur has been removed. After the limb is brought into this 
position a roller is carried from the foot over its entire surface ; 
a large wad of oakum is placed around the wound to absorb the 
discharge, and the roller is carried firmly over the wound, inner 
surface of the thigh, and around the pelvis. I place great impor- 
tance upon this latter part of the dressing, as we thereby compress 
the tissues, and prevent the burrowing of pus, the oakum, which 
has already been placed in the wound, allowing of free drainage, 
no matter how tightly the roller may have been applied. 

Immediately after the patient is dressed in this way, and has 
recovered from the anaesthetic, he is capable of being stood up 
against the wall, or riding out in a carriage or boat, and can take 
his daily exercise in this way. I have, in several instances, had pa- 
tients removed a long distance, some miles, in fact, within an hour 
of the operation, and without the slightest inconvenience or pain. 
This dressing will probably not require to be changed for from 
forty-eight to sixty hours, or until secretion has been formed to 



294 DISEASES OF THE HIP-JOINT. 

moisten the dressings, when the oakum plug can be removed 
without hemorrhage. If this dressing does not come away easily, 
warm-water injections will readily float it out. The wound, 
made clean, is again filled with Peruvian balsam and dressed as 
before. After this it may require dressing once or twice a day, 
according to the amount of discharge, and the child should be 
removed from the entire instrument as often as is requisite. 
The well leg should be removed from the wire breeches at least 
once a week, every day is better, and free movements given to 
all the joints, ankle, knee, and hip, otherwise we may anchylose 
them, although they are not diseased. The wire cuirass should 
be used for from a month to two months, according to necessity, 
after which the patient can be put upon the long or short splint 
and allowed to exercise, thereby increasing his prospects of per- 
fect motion in the new joint. 

The reason for stuffing the periosteum with oakum is because 
we wish it to retain its proper shape, to mould the material 
thrown out for the formation of the new bone that is subsequent- 
ly to bear the entire weight of the patient. If this precaution is 
taken, we may have a femur nearly as well formed as the original 
bone, and equally as serviceable. 

It is impossible to pack the wound with oakum so that pus 
cannot escape through its meshes, hence it is the best substance 
that can be employed, for it permits free discharge from the bot- 
tom of the wound, and at the same time permits firm support to 
the surrounding tissues without endangering the life of the patient 
from absorption of pus or ichor. 

Having completed the dressing, I will stand the patient 
against the wall (see Fig. 177), and I ask you to compare her 
present condition with what it was half an hour since (Fig. 
175). It seems to me that every one who sees it must be con- 
vinced of the propriety of the operation I have just now per- 
formed. 

The long and short splints, and the modes of their application, 
have already been described, and, when the patient has recovered 
from the operation sufficiently to wear one of them, the after- 
treatment of the case is to be continued upon the same general 
plan as that which guides us in the treatment of cases where no 
operation has been performed. Fresh air, sunlight, and good 
food, are the great essentials. Tonics and other remedies may be 



TREATMENT AFTER EXSECTION. 



295 



employed as each case may seem to demand. The wound should 
be kept thoroughly cleansed, and every precaution taken to secure 
a free discharge, so as to prevent the formation of abscesses in 
the surrounding tissues, 

When- the discharge begins to cease, you may commence passive 





Fig. ITT, 



Fig, 177a, » 



motions, and these should be regularly and systematically resorted 
to ; slight at first, but gradually increased as recovery goes on. 

If this treatment is faithfully persisted in, you will be able, 
in a majority of cases, to obtain a much more useful limb than 
Kature can ever produce when she is permitted to effect a cure 
according to her own method, 

I will here insert the first successful case of exsection of the 
head of 'the femur performed in this country, republished in full 
from the.iV^w Yorh Journal of Medicine for January, 1855, in 
order to show the improvements that have been made in opera- 
tion and after-treatment since that time ; 

" On March 20, 1854, I was called, in consultation with 
Dr. Throckmorton, to see Ellen G., 297 Fifth Street, aged nine 
years, who had been suffering for eighteen months with morbus 

1 Fig. 177a is from a photograph of the same patient, seven weeks after the 
operation. 



296 DISEASES OF THE HIP-JOINT. 

coxarius of the left hip, which was supposed to have resulted 
from a fall. She had been treated with issues, blisters, etc., to- 
gether with the general tonic and anti-scorbutic remedies adapted 
to such cases ; but the disease continued to progress, until an 
abscess was discovered, involving the whole upper front and inner 
portion of the thigh, accompanied with repeated chills, profuse 
sweats, and great prostration. 

" When I first saw her, this abscess had pointed in two places, 
and was apparently just ready to open ; the point nearest the sur- 
face and most fluctuating was near the anterior superior spi- 
nous process of the ilium, immediately in contact with the attach- 
ment of the tensor vaginge femoris muscle, and Poupart's liga- 
ment. The other place of pointing was about five inches below 
the ligament, just over the femoral artery ; pressure on any part 
of the upper portion of the limb distended both of these point- 
ing abscesses, showing communication between them. 

" The leg was shortened two and a quarter inches, and turned 
inward, but not permanently fixed in its position (as is usual), 
but allowing of considerable motion, which gave a distinct bony 
crepitus between the femur and ilium. The pelvis was twisted 
and drawn upward. Her general health had become much affect- 
ed ; she had lost her appetite, and was suffering from hectic, with 
constant chills and profuse sweats, and was rendered comfortable 
only by the constant use of anodynes. 

" I advised a free opening of the abscess, and, if necessary, the 
removal of the head of the femur. At first this was objected to ; 
but, as the child's health rapidly failed and death seemed inevi- 
table, the father, in a few days, consented to the operation. Ac- 
cordingly, on March 29, 1854, assisted by Drs. Throckmorton, 
Drake^ Thebaud, Bauer, and Bertholf, I proceeded to perform it. 

" I first laid open the abscess by a free incision of about six 
inches over the trochanter major, on the outer aspect of the 
thigh, and in a line with the femur, and then cut into the floor 
of the abscess (which principally occupied the inner and front 
portion of the thigh), and discharged about a pint of thin serous 
and flaky pus. The finger was then readily passed around the 
neck of the femur, and detected an opening in the capsular liga- 
ment on the inner surface of the neck. The upper border of the 
acetabulum had been absorbed, and the head of the femur was 
upon the dorsum of the ilium, near the anterior superior spinous 



TREATMENT AFTER EXSECTIOX. 297 

process, surrounded hij its capsule (which seemed to have been 
slipped up), and a large deposit of bone, apparently being an at- 
tempt of Nature to make a new acetabulum. But the cavity 
thus formed had no lining membrane, as the femur grated rough- 
ly upon it. I then opened the capsular ligament on a line with 
the external incision, and disarticulated by bringing the leg 
strongly across the opposite thigh, and then, with a large pair of 
Luer's forceps, readily cut off the head of the femur. 1 The bone 
at this point appeared perfectly healthy. 

" The upper rim of the acetabulum had been absorbed (ac- 
cording to the theory of Dr. March, of Albany), and the new 
deposit of bone, which was intended to supply its place, was de- 
nuded and carious. I gouged it off with a sharp, firm chisel, 
made for that purpose, and, in this way, took off a number of 
flakes of bone, until I came to a healthy, bleeding surface. 

" The anterior superior spinous process on its outer surface, 
and the external lip of the crest of the ilium, was black and cari- 
ous for some distance, and with the forceps I easily clipped it off 
until I came to healthy bone. Yery little blood was lost in the 
operation, and, after cleaning away all the debris, I brought the 
leg in the straight position, filled the wound with tow, and dressed 
with a roller and cold-water compress. She was then put to bed, 
and a cup of strong coffee administered, after which she soon fell 
asleep. 

" The child was under the influence of chloroform during the 
operation, which occupied nearly twenty minutes, and was per- 
fectly insensible the whole time. 

" The following extracts from my note-book, taken at each 
daily visit, exhibit the progress of the case : 

" 11 p. m. — Has slept occasionally and is quite comfortable ; 
pulse 128 ; skin good ; vomited freely about 4 p. m. 

" March 30th, 10 a. m. — Passed a good night, without any 
narcotic, and slept about four hours; has had no chill; taken 
breakfast with a relish, and is surprisingly comfortable, consider- 
ing the magnitude of the operation ; pulse 120 ; no haemorrhage ; 
passed urine twice. 

" 31st. — Took half a grain of opium last night ; slept well ; 
pulse 120 ; skin good ; removed external layer of tow ; found small 
amount of pus. 

1 This is the only case in which I have made section of the bone with the forceps. 



298 DISEASES OF THE HIP-JOINT. 

" April 1st. — Slight fever ; heat of skin and thirst ; pulse 130. 
Administered five grains Dover's powder, with addition of half a 
grain ipecac, every four hours. 

" 2d. — Has passed a good night, slept six hours, ate a good 
breakfast, and feels every way better, but is much more feeble. 
Dressed the wound ; on removing the tow, found healthy pus in 
abundance. 

" The abscess, which pointed at the anterior superior spinous 
process, being again full and fluctuating, I opened it, and gave 
exit to about a tablespoonful of tolerably healthy pus ; pulse 140, 
and more feeble ; directed to administer brandy and *beef-tea more 
liberally; I do not think the family give sufficient stimulant or 
nourishment, as they are very strongly opposed to brandy, and 
are afraid of meat on account of fever. 

" 3d. — Slept well all night without opiate ; pulse 120 ; bowels 
moved twice naturally; appetite good; finding great improve- 
ment follow a more nutritious diet I advised its continuance. 

" 5th. — Child very comfortable, amusing herself by cutting 
paper dolls ; applied the straight splint for counter-extension to 
the well side, and made extension by means of the foot-board, 
bringing the limb down to the same length of the opposite one. 

" 'Ith. — Slept well, but much weaker, having had three loose 
discharges in the night, and some haemorrhage from the nose, 
which was arrested by astringents and compress. Ordered brandy 
and laudanum, with more liberal use of iron. 

" 8th. — Diarrhoea not yet checked ; the brandy and opium was 
not given, and yet the child is somewhat stronger than yesterday ; 
pus more consistent. 

" 9th. — Diarrhoea checked ; slept well ; eats freely ; discharge 
less copious and more consistent ; pulse 120. 

" 10th. — Yery comfortable ; looks as if it w T ill require a coun- 
ter-opening on the front of the thigh, at the old place of pointing. 

" 14th. — I applied a compress and adhesive straps on the in- 
side of the thigh. 

" July 1st. — Dr. Throckmorton has seen the child daily since 
my last visit, and reapplied the bandage and compress, which has 
had a most salutary effect, and the abscess has the appearance of 
healing rapidly. 

" 10th. — I was again called to meet Dr. T. to-day, and found 
the child much prostrated from a severe attack of dysentery, 



TREATMENT AFTER EXSECTION. 299 

which had lasted four or five days ; she is very much reduced, 
and, I fear, will not rally. The granulations are flabby, and pus 
thin and copious. 

"August 1st. — The dysentery has been checked for some 
days ; but the wound, which was nearly closed, has opened, and 
a small piece of ragged bone came away, which was probably 
some portion of the shavings or chips removed from the ilium, 
at the time of the operation, and which I had not been sufficiently 
careful to remove. 1 

" 20th. — The child very much improved, but the fistulous 
opening, from which the piece of bone had escaped, remaining, 
and having rather a white and flabby appearance, I injected it 
with tincture of iodine. 

"24#A. — The injection has been followed by a smart attack of 
erysipelas, which has extended down some distance below the 
knee, and there is considerable constitutional disturbance. 

"September 1st. — The erysipelas gradually subsided, but seems 
to have been of great service, as it has caused union of the walls 
of the abscess all around the thigh, and the small opening in the 
cicatrix is nearly closed, discharging a very few drops of healthy 
pus. The limb is still in the extending splint ; but, on removing 
it, there seemed no tendency to retraction of the limb. The splint 
was reapplied ; but the body was left free from the bandage, so 
as to allow of flexion, in order to prevent anchylosis. 

" I might here mention that, for some weeks past, since about 
the 1st of August, at each dressing her body has been brought at 
a right angle with the thighs, having this object in view ; and I 
have now permitted her to do it as often as she likes. 

" November 1st. — I had not seen the case for two months, un- 
til to-day, when, to my astonishment, I found her walking on her 
crutches, which she has been able to do for some two weeks. 
Her limb appears the same length as the other, and she can flex 
and rotate it freely. I directed her to bear no weight upon it 
yet. 

" 20th. — To-day I placed her in the horizontal position, and 

1 " Since making this note, my impressions have been more confirmed, as two simi- 
lar pieces of bone have been removed from different parts of the cicatrix, and have 
thus materially retarded the progress of the case ; I should therefore advise great 
care, after the performance of this operation, that all debris and foreign bodies be 
carefully washed from the wound ; and, in so large and ragged an abscess as this one 
was, it will require more care than any one would imagine, unless they had seen it." 



300 DISEASES OF THE HIP-JOINT. 

measured her carefully, and find there is about one-eighth or 
nearly one-quarter of an inch shortening. By taking hold of the 
foot, the whole body can be drawn down in bed without pain in 
the joint, and a pressure may be made sufficiently strong to move 
the pelvis and body upward without producing any shortening of 
the limb. When she lies upon the back, with the leg extended 
upon the thigh, she can elevate the heel sixteen inches from the 
bed, and flex the knee so as to bring the thigh at a right angle 
with the pelvis ; she can rotate it internally, so as to touch the 
other foot, and externally so as to touch the bed. Her general 
health is perfect, and the case has terminated quite successfully. 
The bone was examined microscopically, but no trace of tubercle 
was found." 

Her present condition is as seen in Fig. 178, from a photo- 
graph. 




Fig. 178. 



As the cases of Koussell, Storch, and Schletting, are among 
the most perfect of my recoveries, and Field altogether the most 
distorted and shortened, I append them with photographs, as all 
the other cases of recovery present various grades of improvement 
between these extremes. I have also added the case of Matilda 



CASE. . 301 

Hillory, because it presents some points of interest, particularly 
the fracture of the femur at the time of the operation. 

These, I think, are sufficient to prove the value and propriety 
of the operation without adding to the expense of the work by 
engraving any of the others, although many of them are nearly 
as perfect as Storch and Schletting. 

Case. Exsection of Hip- Joint ; Removal of Three Inches of 
Bone, and a Portion of the Acetabulum / Reproduction of Bone 
to nearly the Normal Length / Recovery with Perfect Motion. 
(See Table, No. 22.) — Adolph N. Eoussell, aged nine years and 
six months, had hip-disease for four months, the result of a slight 
injury, received while recovering from a severe attack of fever. 
Suppuration soon set in, and, when I saw him, October 20, 1864, 
he presented the usual appearances of the third stage of hip-dis- 
ease, the leg and thigh being well drawn up, and adducted across 
the other thigh. Several sinuses also existed, through which the 
probe readily passed to dead bone in the neighborhood of the joint. 

A free incision was made over the trochanter major, connect- 
ing three or four of the sinuses, and giving exit to a large amount 
of pus. After the escape of the pus, the bones gave distinct 
crepitus on being rubbed together, and an opening Was found in 
the capsule, on its inner and posterior boundary. 

The capsule was laid freely open, and the incision carried 
down over the trochanter major, fairly through the ])eriosteum 
(which Was much thickened) to a point opposite the trochanter 
minor ; the soft parts being well held apart by spatulas in the 
hands of Dr. James S. Steele (who was my only assistant in the 
operation, except my son, a lad twelve years of age), I made an- 
other incision through the periosteum at right angles to the first : 
this division through the periosteum was carried on either side of 
the first, as far around the bone as I could go, making the perios- 
teal cut in the form of an inverted T ( ± ). 

Into the angles thus made, I pressed my periosteal elevator 
(Fig. 112), which is a large and firm instrument, very much like 
the ordinary " oyster-knife." With this instrument the perios- 
teum was readily peeled off, necessarily carrying with it all the 
muscles attached to it, which, in my judgment, is the most im- 
portant feature of the operation, for upon this particular fact 
depends the future usefulness of the limb. 

The cutting edge of the knife was only required to separate 



302 



DISEASES OF THE HIP-JOINT. 



the attachments of the rotator muscles in the digital fossa, "behind 
the great trochanter. All the rest was peeled off with great facil- 
ity on the external portion, and, the thigh being then firmly ad- 
ducted across the other, the bone was easily luxated from the 
acetabulum, and peeled itself off from the internal layer of perios- 
teum, which was left in situ, and thus made a continuous wall or 
layer of dense fibrous tissue, which prevented the burrowing of 
pus on the inner portion of the thigh. 

The femur was then sawed off just above the trochanter 
minor, but, being still further diseased, it was easily pushed up 
through the periosteum, and again sawed off an inch and a quar- 
ter below this point ; the limb then being reduced to its normal 
position, this cuff of periosteum was incised on its outer side, to 
prevent any pocketing of matter. Several pieces of bone were 





Fig. 179. 



easily removed with the forceps from the acetabulum, and the 
whole of the denuded surface thoroughly scraped. 

After injecting the wound with warm water, to wash away all 



CASE. 



303 



debris, the patient was placed in the " wire-breeches," the wound 
filled with Peruvian balsam and stuffed with oakum, and the limb 
extended to nearly its normal length. 

JSTo vessels were tied in the operation. A few strips of adhe- 
sive plaster at either end of the incision, with a firm roller around 
the limb and pelvis, constituted the dressing. 

From the day of the operation he began to improve in his 
general health. A very generous and nutritious diet, with a full 
allowance of ale, together with daily washing of the wound, fill- 
ing it with oakum and Peruvian balsam, and always keeping the 
parts sustained by a well-adjusted roller to prevent the burrowing 
of pus, was the after-treatment. 

After a few days he was able to be carried out to ride, wear- 
ing the wire-breeches. At the end of six months I applied my 
short hip-splint in the daytime, when he could exercise freely 





Fig. ISO. 



Fig. 181. 



with his crutches, and at night I kept up extension by a weight 
and pulley at the foot of the bed. 

The sinuses all healed in about eight months, and at the end 



301 



DISEASES OF THE HIP-JOINT. 



of a year he walked quite well witli crutches, and had only a half- 
inch shortening by the most careful measurement. 

He used his crutches for about eighteen months, and, after- 
ward, a cane for eight weeks, but for the past ten years has not 
used anything, walking without any limp. 

He can run and dance as well as any boy of his age ; in fact, 
he won a pair of skates in a skating-match on the Central Park 
pond, in December, 1869. 

The most remarkable feature of the case is, that the limb con- 
tinues to grow in length as fast as the other, and there is now 
scarcely a half-inch difference in the length of the two by the 
most careful measurement. 

Figures 179, 180, 181, and 182, from photographs, showing 
the result of the operation as well as the bone removed, represent 
the length very accurately, as well as the ability to flex the limb, 




Fig. 182. 



and also to bear the entire weight of the body upon it. I think 
it can fairly be called the most successful case of reproduction of 
the hip-joint that has as yet been recorded. 



CASE. 



305 



Case. — Bernard Storch, aged nine. (See Table, Xo. 31.) Four 
years ago had a fall, since which time he has been troubled with 
his hip. Has been setoned and blistered, without benefit. Con- 
dition, February 25, 1871 : Greatly emaciated, limb shortened two 
inches, adducted, and nearly straight. A large opening, over tro- 
chanter major, has been discharging freely for the past five weeks. 




Fig. 183. 



Fig. 184. 



Fig. 185. 



Finger passes readily into a deep sinus running around the under 
surface of the neck of the bone into the joint. The operation 
was performed by slightly enlarging the external opening at its 
upper border, and carrying the incision down through the perios- 
teum, over the centre of the trochanter major, for about an inch 
and a half ; the periosteum was then divided at right angles to 
the first incision, and peeled off with its attachments, the joint 
freely opened, and the head luxated from the acetabulum by 
strong adduction, and peeled off from the internal layer of perios- 
teum, and sawed off just above the trochanter minor ; the upper 
rim of the acetabulum was absorbed, and the head of the bone 
rested upon the dorsum ilii, but surrounded by its capsular liga- 
ment. Four pieces of necrosed bone, as seen in Fig. 186, were 
20 



306 



DISEASES OF THE HIP-JOINT. 



removed from tlie acetabulum, which was perforated. "Wound 
dressed in usual way, and boy placed in wire cuirass. 

The history presents no points of especial interest. 

He can bear his entire weight upon this limb, as seen in Fig. 
183, can flex it to a right angle, as seen in Fig. 184, and can stand 
with the limbs parallel, Fig. 185. There is a shortening of a 
quarter of an inch. Fig. 186 is from a photograph of the bones 
removed. 






* 




Fig. 186. 



Case.— M. D. Field, aged fourteen years and six months. 
(See. Table, No. 28.) Sixteen weeks previous was struck upon 
right trochanter, producing great pain ; the next day took vio- 
lent exercise and was exposed to cold. This was followed by a 
chill and great pain in hip-joint ; he has not been out of bed 



since. 



A large abscess formed in front of trochanter major, which 
was opened. Condition December 22, 1867 : Emaciated almost 
to a skeleton, very greatly distorted, nine fistulous openings 



CASE. 



307 



around the hip, and the upper part of the thigh distended with 
pus. Trochanter upon the dorsum of the ilium. This is the 
only case of dislocation that I have seen in all ray operations, 
and this took place a few days before the operation, while trying 
to turn him in his bed. 

The head, neck, and four inches of the shaft of the femur, was 
removed in the usual way. 

The head of the femur was entirely out of the acetabulum, 
which was not diseased except at its upper and outer border. 
The entire femnr was surrounded by an involucrum of new bone 
nearly one-eighth of an inch thick. The wound was stuffed with 
oakum, and extension applied. 

The boy improved rapidly, but, the extension having been 
removed, he recovered with nearly four inches shortening, which 
is supplied by a high-heeled boot, and with which he walks re- 
markably well. 





Fig. 187. 



Fig. 1S8. 



He was not seen by me from the time of the operation until 
November 25, 1869, when the photographs (Figs. 187 and 188) 
were taken. Fig. 189 is a representation of the bone as removed, 



308 



DISEASES OF THE HIP-JOINT. 



without having been cleaned or washed, showing that the peri- 
osteum was left entire. 

I saw Mr. Field in August, 1875, and found the motions of 
his joint very materially increased since the photograph was 




Fig. 139. 



taken, from which Fig. 187 was engraved. The leg remains four 
inches shorter than the other. This is the greatest amount of 
shortening which has occurred in any of my cases of exsection, 
and I attribute it to the fact that extension was not continued 
during the progress of treatment. 

The two following cases are added to show that favorable 
results may sometimes occur, even under the most apparently 
unpromising circumstances : 

Case. Exsection of Hi])- Joint; Head and Week absorbed; 
Acetabulum, carious ; Section of the Femur One Inch below Tro- 
chanter Minor ; Recovery, with almost Perfect Form and Motion. 
—In May, 1881, I was requested, by Dr. Wm. H. Church, to 
see a case in consultation of hip-disease, in Fifty-fourth Street, 
near Eighth Avenue. We found a girl (Annetta Schletting), 



CASE. 309 

supposed to be about ten years of age ; her father and mother 
were dead, but the cause of death we were unable to ascertain. 
She was living with some poor relatives, who gave us the follow- 
ing history : Eighteen months before she had fallen from a wagon, 
striking on a curbstone, bruising her right hip and knee very 
badly. She was confined to her bed some days, then got about 
to her play as usual, but was always a little lame in that limb, 
and worse early in the morning, or when commencing to move, 
after some hours of rest. 

About three months after the accident she became much 
worse ; her leg began to " draw up, and turn out," and the pain 
was so intense that they were compelled to give her large doses 
of opium to keep her quiet. Her screams at night, every time 
she fell asleep, were so violent as " to frighten everybody in the 
house." 

This lasted for nearly a year, when suddenly one night the 
leg twisted in across the other foot, and a large swelling came 
on the outside of the hip. 

Since that time she has been much more free from pain, but 
her leg has been fixed in that position, and still remains so. When 
lying on her back, she requires two or three pillows under her 
well limb, which is placed behind the diseased one, and the 
outer portion of the diseased foot is firmly held between the 
great-toe and its adjoining one of the well foot. In this position, 
and at perfect rest, she is comparatively comfortable. The least 
attempt at movement of the diseased limb produces the most 
intense torture. 

About three months after the limb assumed this position the 
large swelling on her thigh broke in three separate places, from 
each of which a copious discharge of pus has continued up to the 
present time. 

A photograph of the girl was taken previous to the operation, 
and it will be observed how she bears almost her entire weight 
by her hands upon the table, and how firmly she grasps the dis- 
eased limb with the well one, for the purpose of preventing mo- 
tion in it. {See Fig. 190). 

On the 8th of May, 1861, assisted by Dr. W. H. Church, I per- 
formed exsection of the hip in the usual way by a curved incision 
over the trochanter major and through the periosteum, which was 
very much thickened. The neck of the femur was entirely ab- 



310 



DISEASES OF THE HIP-JOINT. 



sorbed, and the remains of the head of the bone were lying loose 
in the acetabulum, which was carious but. not perforated. 





Fig. 190. 



Fig. 191. 



Very little blood was lost during the operation, and no vessels 
were tied. She was dressed in the wire breeches in the usual 
way, as previously described. 

The shanty in which she resided, with all the surroundings of 
extreme poverty and foul air, gave very little prospect of a 
favorable result. I therefore moved her out in the yard in the 
open air, under a temporary tent, where she was kept most of 
the time, day and night, except when a severe storm occurred. 

From the day of the operation she improved most rapidly, 
and in less than three months the wounds had healed entirely, 
with less than a half -inch shortening of the femur. In six months 
from the operation she walked well without any support, motions 
of the joint almost as free as normal, and her figure nearly per- 
fect, as seen in Fig. 191, from photograph by O'Neil. 

Case. Exsection of Hip-Joint ; Perforation of Acetabulum ; 
Extensive Intrajpelvic Abscess ; Fracture of Femur at Time of 
Operation • Recovery, with Good Motion and Two Inches Shorten- 
ing. — Matilda Hillory, aged fourteen, Burlington, Iowa, July 3, 
1862. Two years previous pushed over by another girl, striking 



CASE. 



311 



upon lier hip ; for three weeks after gave her great pain when she 
walked. Pain gradually increased. Confined to her bed for 
one year. Six months after commencement of trouble, pain be- 
came much worse at night, with frequent spasms. The limb was 
elongated, abducted, and strongly rotated outward, and could not 
be brought to its normal position. Subsequently the hip began 
to swell, and, six months since, the abscess broke, and at present 
there are four sinuses discharging profusely. Since the breaking 
of the abscess, the patient has been much more free from pain, 
and the limb is shorter, strongly adducted, and fixed against the 
opposite limb, as seen in Fig. 192. One 
of the sinuses, close by the rectum and 
between it and the tuber ischii, dis- 
charged profusely whenever she assumed 
the erect position ; in fact, the pus ran 
down her leg and collected on the floor 
while she was standing for her photo- 
graph. 

July 3, 1862.— Assisted by Drs. Ma- 
son and Shaw, I exsected the hip-joint, 
by making an incision over the posterior 
border of the trochanter major, the in- 
cision slightly curving backward and go- 
ing through the periosteum directly down 
to the bone ; the joint was freely and 
easily Opened, but it was found impossi- 
ble to disarticulate the femur. In using 
force the femur was broken about two 
inches above its lower extremity. 

The finger could be easily passed around the carious bone and 
into the joint, which was filled with spiculse of bone. The neck 
of the femur had been entirely absorbed and yet the shaft 
seemed permanently fixed in the acetabulum, and the limb 
could not be flexed or brought across the opposite one. I there- 
fore passed a chain-saw around the femur and sawed it off, just 
above the trochanter minor. The upper fragment was then 
readily picked out with the dressing-forceps. The difficulty of 
disarticulation was then found to be due to the fact that upon 
the upper end of the femur was a projection three-quarters of an 
inch in length and over half an inch in diameter at its base, which 




Fig. 192. 



312 DISEASES OF THE HIP-JOINT. 

protruded through an opening in the upper wall of the acetabu- 
lum. {See Fig. 193.) The only remnant of the caput femoris 
was a shell of bone which was picked out with the forceps. 
{See Fig. 191.) 

At the insertion of the ligamentum teres was a flattened sur- 
face about the size of a ten-cent piece, which was eroded and 
carious ; and in the acetabulum a similar place at the point of 
contact of the two surfaces. This latter I scraped ; an opening 
was found in the acetabulum which would readily admit the fore- 
finger. The internal periosteum had not been perforated, but 
was separated from the bone, and produced the pouting in the 




Fig. 193. Fm. 194. 



pelvis which had been detected by rectal examination previous 
to the operation. This portion of the acetabulum was carefully 
chipped off down to the attachment of the internal periosteum. 
The wound was thoroughly washed with warm water, dressed 
with Peruvian balsam and oakum, and the patient placed in the 
wire cuirass, which answered the double purpose of sustaining the 
hip, and at the same time providing one of the best appliances 
for the treatment of a fractured femur. 

It is hardly worth while to give the daily details of treatment, 
as nothing unusual occurred, although the case had been compli- 
cated by the fracture. The wounds entirely healed by the 1st of 
October, except the sinus near the anus, which continued to dis- 
charge a small amount of healthy pus. She could bear almost 
her entire weight upon the limb, and had remarkably free volun- 
tary motion of the joint. The limb was two inches shorter than 
the other. 

She left for her home in the West, November 20, 1862, wear- 
ing a long extension-splint, in almost robust health, having gained 
nearly twenty pounds in weight since the operation. 

In 1866 she sent me her photograph, from which Fig. 195 is 



CASE. 



313 



engraved, and in the letter accompanying the same she says : " My 
health is perfect, my limb is as good as the other, and has been 
for two years past, and, with less than an inch on the heel and 
sole of my shoe, I can run and dance as well as any girl in Iowa." 

When this patient was 
brought to me, I gave a very 
unfavorable prognosis of the 
case; her extreme emaciation, 
the extensive intrapelvic ab- 
scess, which was detected by 
the rectal examination, ren- 
dered it, in my judgment, al- 
most certain that no operation 
would be successful, and had 
she been a resident of this city 
I would not have performed it. 
Her limbs were in so awkward 
a position, and her sufferings 
had been so great while she was 
beino' brought from her home, 
that I consented to perform 
the operation merely for the 
purpose of improving her po- 
sition and enabling me to place 

her in the "wire cuirass" so that she could be taken home with 
less suffering than she had endured during her journey here. 
This was distinctly stated to the parents and the physicians pres- 
ent, before the operation was performed. The unfortunate frac- 
ture of her femur, which occurred at the time of the operation, 
compelled me to keep her under treatment, and the result proved 
that my prognosis was not correct. 

The following table of all my cases of exsection of the hip- 
joint, as well as the synopsis of the same, has been compiled 
from my note and case books by my son, Dr. Lewis Hall 
Say re : 




314 



DISEASES OF THE HIP-JOINT. 



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TABLE OF EXSECTIONS. 



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Head of femur ; 

acetabulum 
gouged ; capsule 
ruptured; head 
almost absorbed. 


«a 3 x a 

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"£ 5 ! P 

K 2. a 


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£ ° a 

S3 w © 


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McGlnro, 
11th Ave. 
and 52d St., 
Now York. 




5 S 


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316 



DISEASES OF THE HIP-JOINT. 



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TABLE OF EXSECTIONS. 



317 





Limb was nearly 
well, with limited 
motion ; very slight 
discharge, from 
two sinuses, on 
back of thigh. 
Walked with 
crutches. Went 
into the country, 
and died of dysen- 
tery in Aug., 1864. 






1=2 
© © 

.a .a 
■c «^ 

s ll 

•a o^ 3 


1 ■ 

+3 53 
53 P, 

© 




This is the mo t 

perfect, recovery 

on record. Can 

skate, and dance; 

as well as any one, 

and can kick higher 

than his head. 






00 ,00 






1869. 

18757 




- 


* 


* 


^ 




^ 


* 


Died fourteenth 

day, from double 

pneumonia. 


of 

-b 

ag 


Very good ; walks 

without support ; 

motions of joint 

almost natural. 

Good result, with 

motion. 


Died 
of marasmus and 
cholera infantum. 
August 3, 1866. 


a 

J J" 
•5 lb 

© 


Eecovered with 
good motion. 


1*1 

82 
® . 

** to 

■8 2 

&£* 

© <S> 


Wire- 
breeches. 


i © ~z 

OQ 


Wire- 
breeches. 

Wire- 
breeches. 


1 , «>' 

|.sj 

© c 

1 c ® 
1 « 


Modified 

Hagedon's 

splint. 

Wire- 
breeches. 
Short splint. 


Head, neck, and 
trochanter major. 


Head, neck, and 
trochanter major ; 
acetabulum per- 
forated. 


Head, neck, and 
trochanter major; 
acetabulum perfor- 
ated and gouged. 

Head, neck, and 
trochanter major. 


Head, neck, and 
trochanter major; 
acetabulum per- 
forated and 
gouged. 

Femur above 
trochnnter minor; 
acetabulum per- 
forated. 

Femur above 
trochanter minor. 


Half an inch below 
trochanter minor ; 
acetabulum per- 
forated. 


Greatly exhausted, 
almost in articulo 
mortis; sinuses 
discharging 
profusely. 
Much exhausted 
from long suppura- 
tion, and various 
sinuses. 


CO 

c3 

n 

TS © 
C CO 

o a 

OQ 


§ . 

as 

a 

< 


Emaciated to a 
skeleton. Exces- 
sive suppuration, 
from several 
abscesses. 

Extreme 
emaciation. 

Greatly reduced. 
Several sinuses. 


Reduced to a 

skeleton ; great 
deformity. Exces- 
sive suppuration; 
numerous 
abscesses. 


© 


T3 

O 

. O 

n be 

§3 

© 


Good. 

Previous 

health good. 

Good] 
Health good. 


Father 
healthy. 
Mother 
delicate. 
Child always 

delicate. 
Family his- 
tory good. 

Family heal- 
thy. Boy 
always 
strong. 
Father 
healthy. 
Mother 
delicate. 
Boy always 
delicate. 


CD 

" o "3 
1"° 


Fell out of 

a wagon, 

four years 

before. 


Fall two 
years 
before. 

Fall from 

a stone 
wall, 3 yrs. 

before. 
Fell out of 
her crib, 
two years 
pre- 
viously. 


Fell out of 
bed, 2 yrs 
and 4 mos. 
before. 
Fall nine 
months 
before. 

~~ 'SiighT - 

injury, 

four 

months 

before. 


§£ 

©t- 

fern 


53t-I 


of . 
73 -jo 


•5 to 

2 j° 

63 i -1 

3 


1 - II 
3 l£ 


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Murphy, 
J. W., 307 
E. Sth St., 
New York. 

Rowel, J. F., 
Fordham, 

Westchester 
Co., N. Y. 


Dakin, Ella, 
106 Varick 

St., 
New York. 


Keeler, J., 
138 Mul- 
berry St., 
New York. 


Murphy, M., 

9th Ave. and 

30th St. 

Eoussel, 

A.N. 


>rf lo It-: loo [os d l^-J Icq 



318 



DISEASES OF THE HIP-JOINT. 



? 

s 

1 
T 

Q 

H 
ti 

< 
02 

< 

w 

M 

X 

w 

Q 
W 

« 

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« 

H 

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P 

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03 

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P 

o 
w 

03 

M 
H 


1 


Second operation 
required from leav- 
ing cotton in the 
wound after first 
operation, which 
produced abscesses 
and the necrosis. 


Is now a very 
strong and large 

young man. 
Walks without any 
support, and with 
scarcely a percepti- 
ble limp. 






Wound nearly 
healed in eight 
weeks. Left hos- 
pital much in- 
creased in flesh, 
and in six months 
walked quite well, 
with a high heel on 
boot. 


31 1 




J* 

00 


00 


00 




111 


J* 


:* 


" 


* 


3 


^ CD 

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o> u 


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d.2 

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CD O 

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-do 

O o 

O O 


Can walk on limb, 
but has no motion 

at hip-joint. 
Sinuses remained 
open four years. 


Died of phthisis in 

1869. Wound had 

been healed more 

than a year. 


•« a 


oi 

dg 
® P< 

G CD 




Wire- 
breeches. 
Tonics- 
short splint. 


.si 

iJd ^ 


Wire- 
breeches. 
Iron, qui- 
nine, milk- 
punch, short 
splint. 




"S-o-S 

_^ a M 


Head, neck, and 
trochanter major. 

Second operation, 
May 22, 1865, 

removed six inches 
necrosed femur. 


Head, neck, and 
trochanter major; 
acetabulum per- 
forated and 
gouged. 


Head, neck, and 
trochanter major ; 
acetabulum per- 
forated. 


Head, neck, and 
trochanter major ; 
acetabulum per- 
forated. 


Just above 

trochanter minor. 

Three loose pieces 

of bone removed 

from acetabulum. 


6 . 
H o 

|1 

a 

o 
O 


Great emaciation 
and deformity. 
Several sinuses 
leading to dead 
bone. 


Eeduced to a 

skeleton. 

Numerous sinuses 

on outer part of 

thigti. 


Numerous sinuses. 

Great emaciation. 

Strong adduction 

of limb. 


Very great 

emaciation. Large 

abscess; four 

sinuses. 


Greatly emaciated ; 

several sinuses. 
Left lung very ex- 
tensively tuber- 
culous, but not 
softened. 


o5o 

sill 


.13 

life 


Family his- 
tory good. 
Boy very 
stout and 
strong. 


Good. 
Good pre- 
vious to 
accident. 


Very good. 
Father is a 
remarkably 
strong man. 


Perfect and 

very active. 
Parents 
healthy. 


-CS . 

S| 

1 5 
aft 


Cause not 

known. 
Had been 

lame 
18 months. 


Injured 
his hip, 
going up- 
stairs, two 
years pre- 
viously. 


Fell off a 
wagon- 
step, two 
years and 

four 
months 
before. 


Had been 
lame for 
five years. 
No cause 
ascer- 
tained. 


Fell from 

a swing, 1 8 

months 

before, 

striking 

on her hip. 


°.2 


11 


£ CO 

IS 


00 

>~5 


July 27, 
1866. 


of 

u • 

nCO 

O 


t/3 


s 


a' 


l-v 


Eh' 


&H 


<f 


o 


00 


t- 


s 


eo 


,11 


Watson, 
W. K., 

Sandusky, 
Ohio. 


Brown, 

George, 

Wilton, 

Conn. 


Dugan, C, 
118 Green- 
wich Ave., 
New York. 


Delany, 

Elizabeth, 

611 East 

14th St. 

New York. 


Devine, 

Lizzie, 

447 4th Ave., 

New York. 




CO 
CM 


t)5 

CM 


CM 


SO 
(M 


<M 



TABLE OF EXSECTIONS. 



319 



Walks well with 
high-heeled boot; 
good joint- 
motion. 
(See Figs. 187, 188.) 


Went home to 
Rochester, wound 
nearly healed. 
Was exposed to 
sun, and died quite 
suddenly and un- 
expectedly. 




Had had hip-dis- 
ease of the opposite 

side; recovered 
with angular con- 
traction. This side 
not operated upon. 
Shortening of the 

two limbs about 
equal. 


Wound nearly 

healed, three inches 

of new bone 

formed. 


1 


i— 

oo 










©J 

00 


*# 






Could 
not 
meas- 
ure 
the 
short- 
ening, 
as the 
other 
leg 
was 
dis- 
eased. 




* 


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« 2 

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= ^ §* 

■gS* 

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Anchylosis ; 
acquired' such mo- 
tion at the sacro- 
lumbar articula- 
tion as to compen- 
sate for the loss of 
the joint. 


Died December 15, 

1871, from fatty 
degeneration of the 
liver and kidneys. 


a 
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Femur above 
trochanter minor. 


Remains of femur 
above trochanter 
minor; acetabulum 
perforated. Head 
and neck absorbed. 


Tipper and poste- 
rior border of ace- 
tabulum removed, 

and latter per- 
forated. Head and 
neck of femur had 

already been ab- 
sorbed. 


Femur below 
trochanter minor. 
Acetabulum per- 
forated and gouged. 


c3 =3 


Emaciated to a 
skeleton ; greatly 
distorted. Tro- 
chanter on the dor- 
sum of the ilium. 
Nine sinuses. 


Greatly emaciated. 

Excessive 

discharge from 

several sinuses. 


Great emaciation. 
Excessive suppura- 
tion from several 
sinuses. 


Leg flexed at an 
acute angle, and 

strongly adducted. 

Mode of locomotion 
on all-fours. 


Reduced to a 
skeleton from ex- 
cessive suppura- 
tion. 


Leg flexed and ad- 
ducted. Greatly 

reduced by exces- 
sive suppuration. 


Parents 

healthy. 

Boy strong 

until 

accident. 


Good. 
Good pre- 
vious to 
accident. 


Mother 
healthy. 
Father 
delicate. 
Child always 
delicate. 


Good. 

Previous 

health good. 


^.2 §> 
© f* rt 

X\ 


No previous 

history of 

this case 

could be 

obtained. 


Blow on 
trochanter 
major, 
four 
months 
before. 


From a 
jump and 
fall, six 
years 
before. 


Fell on 
bricks in 
the yard, 
six years 

before. 


Fell from 
a swing, 

six months 
before. 


Lame for 
six years. 
No cause 
ascer- 
tained. 




is 

goo 
©1-1 


May 24, 
1868. 


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511 


Jacqueth, 

Sarah, 
Rochester, 
New York. 


&§ . 
-©-I* 32 


Sutherland, 

George, St. 

Catharine's, 

Canada. 


Williams, 
Lyman. 


Woods, W., 

Child's 

Hospital, 

Randall's 

Island. 


00 

©> 


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CO 1 CO ' CO 



320 



DISEASES OF THE HIP-JOINT. 



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Died in summer, 
1874, from exhaus- 
tion. Hip-joint 
well, but had ne- 
crosis of greater 

part of ilium. 

Should have been 

operated upon six 

months sooner. 




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Walks with 

crutches, wound 

healed, but has 

slight discharge 

from another sinus 

leading to posterior 

crest of ilium, but 

cannot touch dead 

bone. 


Perfectly well, 
with good motion. 

Can walk well, 
with a very slight 

halt. Can run 
without the halt. 




Wire- 
breeches. 
Short splint. 




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Head loose, neck 
diseased. Acetab- 
ulum perforated 

and gouged. 

Trochanter major 

removed. 


Head, neck, and 
trochanter major 

removed. Acetab- 
ulum perforated 
Large quantity of 

bone removed from 
ilium. 


Head and neck of 
femur entirely de- 
stroyed. Carious 
abscess in the tro- 
chanter major ; 
gouged; acetab- 
ulum perforated 
and gouged. 


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Greatly emaciated. 

Profuse discharge ; 

sinuses, great 

deformity. 


Great emaciation. 

Excessive dis- 
charge from four 
sinuses. 


O 3 O 

■Jo j 


Very good. 

Parents 
remarkably 

healthy. 


Parents 
healthy, but 
very diminu- 
tive. 


Mother died 
of consump- 
tion. Father 

healthy. 
Boy delicate. 


Father died 
of phthisis. 
Mother very 

healthy. 
Child rather 

delicate. 


go 


jjg'S 

3*2 


— CQ 

9^=2 


Struck by 

a stone in 

groin, four 

years 

before. 

Again hurt 

by a fall 

from a 

wagon, 

NovembV, 

1871. 


9 ^<2 

OOJ 


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Storch, 

Bernard, 

Hudson 

City. 

New Jersey. 


Zittle, P, 

222 East 

62d St, 

New York. 


O'Farrell, 
Matthew, 
22(5 East 
37th St, 
New York. 


Ward, 

Martin, 
Manhattan- 

ville. 
New York. 




SS 


CO 


CO 


CO 



TABLE OF EXSECTIONS. 



321 



This is the oldest 

case of any exsec- 

tion of hip for 

disease. 


Wound about hip 
nearly healed. 

Abscesses formed 
in thigh below, 
after operation. 






g 




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CO 




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- 


3 


Has a useful and 
movable joint. 
Is engaged in 

active practice in 
Michigan. 


Died in three 

weeks, of amyloid 

degeneration of 

kidneys. 


Tolerable motion, 

and can bear his 

weight on the 

limb. 


Can walk without 

crutch or cane. 

Good motion of 

joint. 


Modified 

II aged on 

splint. 

Short splint, 

with 

rotating and 

abducting 

screws. 


i © 

© J3 


jjj m 

OQ 


ill 
Ml 


Head, neck, and 
trochanter major ; 

acetabulum per- 
forated and gouged. 


Head, neck, and 
trochanter major ; 
acetabulum per- 
forated ; lower por- 
tion of femur 
necrosed. 


Femur just 
above trochanter 
minor ; head and 
most of neck ab- 
sorbed. Acetab- 
ulum perforated, 
and an abscess in- 
side the ilium. 


Eemains of head 

and neck of femur. 

Head and neck 

nearly absorbed ; 

acetabulum filled 
with new bone. A 
new facet formed, 
on which the end 

of femur rested. 


Great emaciation ; 

profuse discharge ; 

suffers intense 

pain, which 

requires the use of 

large doses of 

morphine. 


™ -i 

3.5 

■° a, 

fl 

© 


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Limb adducted, 

flexed, and fixed ; 

sinuses near groin 

discharging. 


Parents 
both 

healthy. 
Has always 
been strong 
and active. 


c5 6o 


Good. 

Always 

strong and 

active. 


« 60 

• s 9 

'O.Q © 

o c h 
c ■ u t5 

5§ 


From fall 
at three 
years of 
age, re- 
sulting in 
anchylo- 
sis, with 
eight 
inches 
shortening 

when 
nineteen. 
Disease 
developed 
in 1872 
from an 
accident. 


From an 

injury six 

months 

previous. 


3 02 


From a fall 

ten and a 

half years 

before. 


goo 
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so 






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CO ■ 


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Maiden, Dr. 

William P., 

Alpena, 

Michigan. 


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3 


Morpie, 

Malinda, 
736 1st Ave., 
New York. 


CO 
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21 



29,9, 



DISEASES OF THE HIP-JOINT. 



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Died May 6, 1875, 
from sudden sup- 
purative nephritis. 

Passed a large 
quantity of pus by 
the urethra for two 
or three days pre- 
vious. Had good 

motion; wound 
closed, except sinus 

over pubis, from 

which a few drops 

of pus discharged 

daily. No autopsy 

made. 


Died June 17, 1874, 

from dysentery. 

Wound entirely 

closed for four 

months. 


This case was oper- 
ated on with no 
prospect of success, 
as he had waxy 
kidney and liver, 
which no doubt 
still exist, but he 
was made comfort- 
able and his hip 
well for 18 months. 
Died January 12, 
1875, from nephri- 
tis from cold. 






1*4 

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£g.S 


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Limited motion. 
Walks with exten- 
sion splint, without 
crutch or cane. 


Movable joint; 
able to bear entire 

weight on limb. 
Anasarca removed, 
health vastly im- 
proved; cheeks 
ruddy. 


5J| 


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Diseased end of 
femur and portion 

of acetabulum. ' 
Head and neck en- 
tirely destroyed, 
and shaft per- 
forated the acetab- 
ulum. 


Femur just 
above trochanter 
minor. Portions 
of necrosed bone 
from the acetab- 
ulum, which was 

perforated. 


Femur just 

above trochanter 

minor ; acetabulum 

gouged. 


g 
H g 

SO 

■a 
c 

6 


Abscesses about 
joint ; one over 

symphysis pubis. 

Great emaciation. 


Extensive abscess 

on outer part of 

thigh. Greatly 

emaciated. 


i $ 

£? ^ § 

1 


11% 

g Jofl 


Parents 
perfectly 
healthy. 
Child healthy 
previous to 
accident. 


Parents 
healthy. 

Child well 
before 

accident. 


Good. 

Health good 

until eight 

years ago. 


-a - 
o 
g'| 

i 3 
ofl 


From a fall 
from a 
wagon 
when 

23 months 
old. 


From a 

blow from 

a stone, 

ten 
months 
before. 


Eight 

years' 

standing. 

No cause 

known. 

• 


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Gregory, 
E. S., 

Houston, 
Texas. 


Hudgins, 

Maud, 
Hampton, 
Virginia. 


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TABLE OF EXSECTIO^ T S. 



323 



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324: 



DISEASES OF THE HIP-JOINT. 



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TABLE OF EXSECTIONS. 



325 





September 23, was 
taken to the photo- 
grapher's to have 

picture taken 
from which Fig. 
197 is engraved. 


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*l 
a v 

If 

Q 






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<j}CO 


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■gfe 














111 

o-rr u 
-rt ^ ° 

.3.91 


Wound entirely 
closed, without 

shortening. 
Good motion. 




."a 

i ce s 

^5g 

Hi 


Wire- 
breeches. 
Tonics, etc. 
Long splint. 
Short splint. 


Wire- 
breeches. 
Tonics, etc. 
Long splint. 


Wire- 
breeches. 
Tonics, etc. 
Long splint. 


Head partly ab- 
sorbed, and lying 
loose in acetab- 
ulum. Femur 
sawed above tro- 
chanter minor. 
Several pieces of 
necrosed bone 
picked out. 


Head nearly ab- 
sorbed, a small 

piece of it lying 
loose in acetab- 
ulum, Femur 

sawed above tro- 
chanter minor. 

Acetabulum per- 
forated and gouged. 

Sinuses on thigh 
scraped out. 


Head, neck, and 
part of trochanter 

major absorbed. 
Three small pieces 
of bone removed 
from acetabulum, 

which was per- 
forated, and end 

of shaft sawed 
smooth. 


Head, neck, and 
trochanter major. 
Acetabulum per- 
forated. A number 
of small pieces 
of bone were 
picked out of the 
acetabulum. 


Very much 
emaciated. Hectic. 
Large abscess over 
trochanter major. 


Keduced extreme- 
ly. Several sinuses 
about hip. 
Extreme distor- 
tion. 
(See Fig. 195.) 


Wasted to a skele- 
ton. Abdomen 
very much dis- 
tended. A large 

opening on poste- 
rior part of hip. 


-& r i co 
.So§ 

°a 2-i 
S3* 

111 

So 32 


Parents 

healthy. 

Stout, active 

boy, until 

accident. 


No family 
history or 
account of 
any kind 
could be ob- 
tained, as the 

child's 
mother is in 
the insane 
asylum, and 
father dead. 


Was 
always heal- 
thy until one 
year ago, 
when she 
had dysen- 
tery. 


Was 
always very 
healthy and 

active. 
Family his- 
tory very 

good. 


Fall 

18 months 

before, 

striking 

on knee. 


*a a' 
o £ 


Cause not 
known, 
followed 

severe ill- 
ness one 

year ago. 


Injury 
two and a 
half years 

ago by 
jumping 

from a 

stoop. 


5 12 

P,tH 


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,o id 

as 

CDt-I 

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CD i-t 

CD CN 

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Jo 

a cs cd 

cp > 43 
S;a * 

CO" 

o 


Rosa 
Mullins, 
246 West 
47th St. 


Mary 

Mahoney, 

W. Houston 

St. 


35 


iO 


CO 


<5 
o 



326 DISEASES OF THE HIP-JOINT. 

SYNOPSIS OF FIFTY-NINE CASES OF EXSECTION OF THE HIP-JOINT FOE 
MORBUS COXAEIUS. 

Thirty-nine of these cases are now alive. Of these, twenty 
recovered with motion, and less than one inch shortening ; eight 
recovered with motion, and more than one inch shortening ; two 
recovered with anchylosis, and nine are still under treatment, 
with every prospect of good results. 

Twenty of these cases are now dead. The cause of death in 
each case, as well as the length of time after the operation, is as 
follows : 

Case 2 died from exhaustion on the eighth day. 1 

Case 3 died from exhaustion in two months. 

Case 10 died from tetanus on fifteenth day. 

Case 14 died from exhaustion in two weeks. 

Case 15 died from double pneumonia on fourteenth day. 

Case 16 died from dysentery seventeen months after the operation, 
wounds having been almost closed for some months. 

Case 19 died from marasmus two years and two months after the opera- 
tion. Wound had been closed for six months. 

Case 20 died from dysentery in two weeks. 

Case 23 died from dysentery eight months after the operation. 

Case 27 died from phthisis two years after the operation. Wound healed 
for more than a year. 

Case 29 died from sunstroke from exposure on fortieth day. 

Case 30 died from exhaustion in three weeks. 

Case 32 died from fatty degeneration of the liver and kidneys twenty- 
three months after the operation. Wound nearly healed ; three inches of 
new bone formed. 

Case 36 died from exhaustion in eighteen months, from progressive dis- 
ease of the ilium. 

Case 39 died from amyloid degeneration of kidneys in three weeks. 

Case 42 died from sudden suppurative nephritis, two years and three 
months after the operation. For nearly a year had been able to walk with- 
out support. 

Case 43 died from dysentery thirteen months after the operation. Wound 
had been entirely closed for four months. 

Case 44 died from nephritis from cold, nineteen months after the opera- 
tion. Had been well for nearly a year. 

Case 47 died from exhaustion two and a half months after the operation. 

Case 49 died from exhaustion in one month. 

Of these twenty cases that died, eight had recovered from the 
operation some time previous to death, which was caused in each 

1 The figures refer to the number of the case in the table. 



SACEO-ILIAO DISEASE. 327 

case by some other disease entirely foreign to the operation (cases 
16, 19, 27, 32, 36, 42, 43, 44). 

Of the twelve remaining, four died from acute intercurrent 
diseases, such as tetanus, double pneumonia, dysentery, and sun- 
stroke (cases 10, 15, 23, 29). This leaves but eight who have 
died from the exhausting effects of hip-disease, without some in- 
tercurrent complication (cases 2, 3, 14, 20, 30, 39, 47, 49). 



LECTUKE XXIY. 

DISEASE OF THE JOINTS. THE DISEASES WHICH SIMULATE HIP- 
DISEASE. 

Sacro-Iliac Disease. — Disease of the Knee. — Caries of the Ilium. — Caries of the Ischi- 
um. — Periostitis of Adjacent Parts.— Psoas Abscess with Pott's Disease. — Ingui- 
nal Abscess. — Inflammation of the Psoas Magnus and Iliacus Internus Muscles. 
— Congenital Malformation of the Pelvis, commonly known as " Congenital Dis- 
location." — Paralysis of the Lower Extremities. — Injuries of the Hip, including 
Diastasis, Fractures, and Dislocations. 

Gentlemen : At my last lecture we completed the study of 
hip-disease, and I invite your attention this morning to some of 
the diseases which simulate it. 

Hip-joint disease is liable to be confounded with sacro-iliac 
disease ; disease of the knee ; caries of the ilium or ischium ; 
periostitis of the parts adjacent to the hip-joint, particularly of 
the great trochanter. It is more rarely confounded with psoas 
abscess associated with Pott's disease ; inguinal abscess ; inflam- 
mation of the psoas magnus and iliacus internus muscles ; con- 
genital malformation of the pelvis, commonly known as " con- 
genital dislocation;" paralysis of the lower extremities, and in- 
juries to the hip. 

Sacro-iliac Disease. — The anatomy of the sacro-iliac junction 
is thus given by Gray : 

" The sacro-iliac articulation is an amphiarthrodial joint, 
formed between the lateral surfaces of the sacrum and ilium. 
The anterior or auricular portion of each articular surface is 



328 DISEASE OF THE JOINTS. 

covered with a thin plate of cartilage, thicker on the sacrum than 
on the ilium. 

" The surfaces of these cartilages in the adult are rough and 
irregular, and separated from one another by a soft, yellow, pulpy 
substance. At an early period of life, occasionally in the adult, 
and in the female during pregnancy, they are smooth and lined 
by a delicate synovial membrane. The ligaments connecting 
these surfaces are the anterior and posterior sacro-iliac. 

" The anterior sacro-iliac ligament consists of numerous thin 
ligamentous bands which connect the anterior surfaces of the 
sacrum and ilium. 

" The posterior sacro-iliac is a strong interosseous ligament, 
situated in the deep depression between the sacrum and ilium 
behind, and forming the chief bond of connection between these 
bones. It consists of numerous strong fasciculi, which pass be- 
tween the bones in various directions. Three of these are of 
large size. The two superior, nearly horizontal in direction, arise 
from the first and second transverse tubercles on the posterior sur- 
face of the sacrum, and are inserted into the rough, uneven sur- 
face at the posterior part of the inner surface of the ilium. The 
third fasciculus, oblique in direction, is attached by one extremity 
to the third or fourth transverse tubercle on the posterior sur- 
face of the sacrum, and by the other to the posterior superior 
spine of the ilium ; it is sometimes called the oblique sacro-iliac 
ligament. There is only very slight movement between the 
bones themselves." 

Disease of this joint is quite common, and is invariably of 
traumatic origin. I have seen a number of cases in which the 
disease originated in injuries received by the little patients as they 
slipped over behind a trunk and got caught between it and the 
wall, where they were doubled up very tightly. In their efforts to 
get out while jammed down between the trunk and the wall, the 
junction of the sacrum and ilium is brought in contact with the 
edge of the base-board, and gets bruised sufficiently to set up an 
inflammation of the parts injured. 

While the inflammatory process is going on, the patient will 
complain of difficulty in making water, difficulty in having a 
movement from the bowels, and more or less pain in the bowels ; 
in short, the same class of symptoms referable to the front part of 
the body of which the patient complains who has Pott's disease 



SACRO-ILIAO DISEASE. 329 

of the spine. After a while an abscess may show itself, which 
may be posterior at the upper part of the sacrum, or up along the 
side of the spine, or extending in various directions, and may 
possibly work its way through between the sacrum and ilium, and 
appear upon the anterior portion of the thigh. 

Of course, when it has reached this point, it is almost a hope- 
less case for treatment. The symptoms which are present in the 
early stages of the disease are very much like those of hip-joint 
disease. 

That is, the child cannot walk without limping, and walking 
also gives him pain. Concussion of the head of the femur 
against the acetabulum also causes pain. Crowding upon the 
great trochanter causes pain, because the pressure is transmitted 
through the ilium to the part involved by the disease. 

But, when the wings of the ilia are held firm, and then an 
examination of the hip-joint made in the manner described to 
you when speaking of hip-disease, no pain will be produced, 
and free motion can be made. In hip-disease, abduction or rota- 
tion outward, or adduction or rotation inward, depending upon 
the stage of the disease present, aggravates to a greater or less 
extent, often almost intolerably, the sufferings of the patient. In 
this manner you can exclude the probability of disease of the 
joint. 

]Now make direct compression upon the wings of the ilia, 
crowding the bones against the sacrum, and you will produce 
pain at once, and at the seat of the disease. If extension is 
made, the pain will be relieved, and that is also true of hip- 
disease ; but, when the pelvis is firmly held, and compression 
made of the hip-joint only, it will not develop pain if the disease 
is at the sacro-iliac joint, but it will develop pain if the disease 
is at the hip-joint. 

JSTow turn the patient upon the face, and make pressure along 
the line of the sacro-iliac junction, and you will find that the 
greatest degree of pain is produced in that region. There may 
be more or less tenderness all over the gluteal region and about 
the hip- joint, but the greatest amount of pain will be produced 
by pressing immediately over the articulation. 

In sacro-iliac disease there is no abduction or eversion of the 
limb as there is in the first and second stages of hip-disease, but 
simply elongation. On the contrary, the distortion present in 



330 



DISEASE OF THE JOINTS. 



sacroiliac disease is a distortion of the body. (See Fig. 196.) 
The patient bends the body over to the opposite side, so that the 
weight of the limb may make extension sufficient to give relief 




Fig. 196. 



to the diseased articulation. (See Fig. 197.) This bending over 
to one side, for the purpose of removing pressure from the dis- 
eased structures by bringing the weight of the limb to bear upon 
the ilium, produces a deformity that is peculiar and characteristic 
of sacro-iliac disease. (See Figs. 197 and 198.) 

In sacro-iliac disease the lengthening of the limb is absolute, 
while in hip-joint disease it is only apparent. In hip-disease the 
elongation is discovered by measuring from the anterior superior 
spinous process of the ilium to the internal malleolus, and is 
caused by the effusion into the hip-joint. The elongation is 
apparently greater than it really is, and is due to the twisting of 
the pelvis. In sacro-iliac disease the distance between the mal- 
leolus and anterior superior spinous process of the ilium is the 
same upon both sides. "When the disease has progressed so far 
that abscesses are present and openings formed, it should be recog- 
nized at once ; for, by means of the flexible or vertebrated probe, 
dead bone can often be detected. 



TREATMENT. 



331 



Treatment. — The principles of treatment are the same which 
guide us in the treatment of all joint-diseases, namely: rest, 
extension, and counter-extension. We must devise some means, 
however, if possible, by which we can apply extension without 





Fig. 197. 



Fig. 198. 



confining our patient in bed. This can be very easily accom- 
plished by making the sole of the shoe worn upon the well foot 
of sufficient thickness to permit the affected limb to swing free, 
so that its own weight may become an extending force. If the 
weight of the limb is not sufficient to make the amount of exten- 
sion required, lead can be run into the sole of the shoe, and thus 
the weight can be increased as circumstances may require. Now 
give the patient a pair of crutches, so that the weight of the body 
shall be received by the axillse and not by the pelvis, and all the 
indications in treatment have been met. Darrach's wheel-crutch 
is a very admirable support in these cases. If the case is one of 
long standing, and there is more or less deposit in and about the 
joint, or if the inflammation does not readily subside, application 
of the actual cautery directly over the sacro-iliac articulation will 
be of the greatest service. The actual cautery is preferable to 
any other means of counter-irritation. There is nothing like the 



332 DISEASE OF THE JOINTS. 

action of intense heat in the treatment of many of these cases. 
There is a relaxed condition of the ligaments, and an engorged 
state of the blood-vessels, which can be more effectually relieved 
by the use of the actual cautery than by any other means that 
can be employed. The contractility of the blood-vessels is ex- 
cited, by which means they are emptied, and in this manner 
venous engorgement is relieved, and, as the wound heals up, the 
cicatrization that follows contracts and condenses the ligamentous 
structures in such a manner as to firmly hold the joint in position 
when recovery has taken place. If the disease has progressed, 
and suppuration becomes established, then, instead of cauteriza- 
tion, lay the parts open freely, passing down until you have laid 
the joint bare, and, if the probe detects dead bone anywhere, fol- 
low it up by freely laying the sinuses open, or make counter- 
openings, and gouge it out, for it must be removed before the 
patient can get well. 

Case. — Psoas Abscess from Sacro-Iliac Disease mistaken for 
Hip-Disease. — Cornelius M., aged four years and nine months, 
came to me at Bellevue Hospital, December 15, 1872, to be treat- 
ed for disease of the right hip- joint. He had been complaining 
for some months and had been lame for several weeks ; had com- 
plained all summer of stomach-ache, and had been treated for 
worms, but for the past two months had been treated for hip- 
disease, and was sent to me to be treated for that disease. Upon 
a careful examination before the class, I could find no disease of 
either hip-joint, but a manifest tenderness over sacro-iliac junc- 
tion of both sides, but more particularly on the left side. Eo 
swelling of the inguinal glands on either side. The mother states 
that he was a very active child, and his father used to make him 
jump over boxes, and from great heights, and in one of these 
jumps he hurt his back, but they had forgotten this fact, until I 
questioned her upon the subject. I lost sight of this child until 
January, 1874, when he was again brought to the hospital, pre- 
senting the appearance as seen in Fig. 199. An immense ab- 
scess on the left groin nearly ready to burst. No disease in 
either hip, but well-marked disease in both sacro-iliac junctions. 
Boy died June 10, 1874, from exhaustion; was seen twenty-four 
hours before death, and was found to be dying from the exces- 
sive discharge from a sinus existing in the inguinal region, and 
a sinus. on upper and outer portion of thigh. 



SACRO-ILIAC DISEASE. 



333 



Post mortem, twenty-four hours after death, revealed exten- 
sive caries of both sacro-iliac junctions, and extensive abscess ex- 
tending down psoas muscles on either side, on the left coming 
out above Poupart's ligament, and on the right passing under the 




Fig. 199. 

ligament and extending down the thigh. Both hip-joints were 
perfectly healthy. 

Knee-joint Disease is sometimes mistaken for morbus coxa- 
rius. The pain of hip-joint disease is very often referred to the 
knee, thereby causing the disease to be mistaken for synovitis of 
the knee-joint. So also when the knee-joint is really diseased 
the deformity present may simulate that which is seen in the 
second stage of hip-joint disease. 

The position of the limb in disease of the knee is one simply 
of flexion at the knee and hip, accompanied with dropping of the 
corresponding natis. The dropping of the natis is caused by 
throwing the weight of the body upon the sound limb and allow- 
ing the diseased limb to be pendent. At a later period in the 
disease it may depend upon the muscular contraction which 
attends chronic disease of the knee-joint. 

The position of the limb in the second stage of morbus coxarius 



334 DISEASE OF THE JOINTS. 

arises from effusion within the capsule and contraction of the 
psoas and iliacus muscles, and is an anatomical necessity. 

So far as position is concerned, then, the difference in origin 
is important in the differentiation of the two diseases. Again, 
the position of the limb in hip-disease is constant as long as the 
effusion remains within the capsule ; while the position in knee- 
disease may be varied at will. 

In hip-disease, second stage, the limb is always in advance of 
the sound one, the toe touching the floor ; while in knee-disease 
it is sometimes in front for the sake of comfort, but the patient is 
able to bring the heel behind the sound one, and often does so 
place it, or even bring it to the ground, and is able to. evert or 
invert, adduct or abduct the limb at pleasure. When the patient 
can perform these movements you may be certain that the second 
stage of morbus coxarius is absent. 

When knee-disease has advanced to a considerable degree, 
there is strong adduction of the limb for the sake of balance ; 
the popliteal space closely hugs the patella of the sound knee, 
and the heel is generally behind the sound one, but sometimes it 
may be carried forward for the sake of resting. 

In the third stage of hip-disease, for which advanced knee-dis- 
ease is perhaps more likely to be mistaken, there is adduction, 
raising of thejpelvis and whole limb, inversion of the foot so that 
the toe of the diseased side rests upon the instep of the sound 
foot. 

Caeies of the Ilium. — This affection has been frequently mis- 
taken for hip-disease. A deformity may be present, and it may 
be accompanied by an excessive discharge of pus, and many other 
symptoms of hip-disease; but the peculiar deformity which is 
present when the hip-joint is involved is not seen in cases of caries 
of the ilium. Abduction and eversion at a certain stage are not 
necessarily present, as in the second stage of hip-disease ; nor are 
adduction and inversion necessarily present as in the third stage 
of hip-disease. 

A diagnosis in these cases is to be made to a certain extent by 
exclusion. If we place the patient in the position so frequently 
referred to, with the pelvis and trunk in proper relation to each 
other, and^a? the pelvis, slight motion can be made at the hip-joint 
without causing pain, so long as the ilium is held firmly in posi- 
tion. 



CARIES OF THE ILIUM. 335 

Your direct examination is to be made with the probe, which 
will enable you to determine whether there is any dead bone or 
not. For this purpose the flexible probe is the only one that 
should be employed, for it will follow a lead but will not make an 
opening. 

If you will remember the points in diagnosis of hip-disease 
and keep them accurately in your mind, it seems almost impos- 
sible to confound it with caries of the ilium. 

As I shall not lecture upon caries of the ilium separately, I 
will mention the treatment in this connection. 

Treatment. — This is simple, and consists in making a free in- 
cision down to the dead bone and removing it. If the disease in- 
volves parts of the ilium where it would be dangerous to cut, the 
sinuses may be dilated by means of laminaria or sponge-tents, 
until they are of sufficient size to permit the introduction of the 
elevator for the purpose of clipping off what dead bone can be 
easily reached, and then removing it with the forceps. If it is not 
possible to remove all the dead bone at once you may drill through, 
pass in oakum strings or India-rubber drainage tubes, and wait 
until Nature removes the remainder by exfoliation. The danger 
in these cases is not from dead bone, but from imprisoned pus. 
making tortuous sinuses in different directions and ultimately pro- 
ducing death from exhaustion. Therefore, if you are not able to 
remove all the dead bone at once, if you can establish a free drain- 
age in the proper direction, you have done the best possible thing 
for your patient in the way of local treatment. 

Case. — Thomas K. C, aged fourteen, Jersey City, E". J. In 
infancy puny and feeble, inactive, walked when three years old ; 
was fleshy but unhealthy, has improved since he was five or six 
years old. In summer of 1864 had nates repeatedly bruised by 
kicks, and by riding a rough-trotting horse. The bruises were treat- 
ed with the usual domestic remedies. In the fall he was again 
injured by being thrown down the stone steps at school, and tram- 
pled on, and was also severely beaten by a man with a heavy cane. 
Soon after this the boy began to suffer from cramping pains in 
the left toes, the pains gradually extending up to the hip. The 
surgeon who saw him thought an abscess was forming which would 
result in hip-disease. There was an extensive swelling over the 
lower part of his back, but no pointing to indicate its exact local- 
ity. In the summer of 1865 an abscess was opened in the left 



336 



DISEASE OF THE JOINTS. 



gluteal region, and discharged from it a very large quantity of 
pus. For a while he seemed to improve, but in the fall of 1865 he 
had general anasarca from anaemia, and it was thought his case 
would terminate fatally. All the physicians who had been con- 
sulted looked upon it as a case of advanced hip-disease. He was 
sent to the country in the fall of 1865, and used iron and cod-liver 
oil freely. He improved for some time, but in the spring of 1866 




Fig. 200. 



another abscess formed lower down on the buttocks, when he was 
seen by a surgeon in Ohio, who called it hip-disease. During the 
summer of 1 866 another abscess formed, making four in all. Dr. 
C. Grahn, of the Ohio Medical College, then saw him, and was the 
first who said it was not a disease of the hvp-joint. Various salves 
and ointments were applied to the sores, which continued to dis- 
charge more or less until August 16, 1868, when he was brought 
to me in the condition seen in Figs. 200 and 201, with several 
sinuses on the nates near the sacrum, as seen in Fig. 200, and two in 
the perinseum, as seen in Fig. 201, all leading to dead bone on the 
back of the ilium, and the tuberosity of the ischium, but the hip- 
joint was perfectly healthy, and had never been involved in the 
disease. By dilating the various fistulous openings with sponge- 
tents, I was able in a few days to pass a flexible silver probe from 



CASE. 



337 



the posterior openings through, to the perinaeum, as seen in Figs. 
200 and 201 (1, 1, and 2, 2, represent oakum setons drawn through 
the fistulous tracts by the side of the dead bones). One piece of 
bone about the size of the thumb-nail was knocked off, and came 
out entangled with the oakum on the first day. This oakum was 
saturated with Peruvian balsam, and the concealed part drawn 
through daily, and the soiled oakum cut off. Small pieces of 
bone continued to come away for three or four months, but the 




Fig. 201 



boy's health began to improve from the day free drainage was 
established, and he began to have more use of his limbs. By 
passive motions, friction, and frequent handling, he gradually re- 
covered his perfect form, as seen in Fig. 202, and was discharged 
cured, and \^it\\ perfect motion, in June, 1869.- I received a letter 
from his father, Rev. T. K. C, dated April 27th, 1871, saying: 
" Our Tom is a trump, that you know is the short for triumph. 
He can run through a troop and leap a wall, he can ably wrestle 
against flesh and blood ; he can travel on his muscle. Without a 
doubt the very best reason is, the fact of your frequent manipula- 
tions of the boy. ... He and we all feel very grateful to Dr. 
Sayre." 

March 7, 1873. — Father called to say Tom was in excellent 
condition. 

Caries or the Ischium is more deceptive than the last-named 
disease. 

22 



338 



DISEASE OF THE JOINTS. 



The following case, which was under the care of Mr. Callender, 
has been taken from the report made in the British Medical 




Fig. 202 

Journal for July 22, 1871, and was mistaken for hip-joint dis- 
ease: 

Case. — u About six years ago, A. R., aged forty-five, by occu- 
pation an omnibus-driver, first noticed some tenderness about the 
left gluteal region, which was followed by swelling, and ultimately 
by the formation of an abscess in the ischio-rectal fossa and middle 
of the back of the thigh, which broke about twenty months ago, 
and has been discharging ever since, despite treatment at various 
institutions. 

" Several sinuses, with pouting, granular orifices, occupied the 
left ischio-rectal region, and one sinus had its opening on the 
middle of the back of the left thigh. Into any of these a probe 
could be passed in the direction of the tuberosity of the ischium ; 
but, owing to the tortuosity of the passage, failed to reach any 
dead bone. Dr. Sayre, who saw the case at a consultation on the 
13th inst., remarked on the coincidence that it was in a precisely 



CASE. 339 

similar case that he first used Ms flexible probe in America, and 
this instrument traversed with great ease the winding course of 
the sinus until its point was distinctly arrested by bare bone. 

" On the following Saturday, Dr. Sayre being present at the 
operation, a free incision was made over the left tnber-ischii, and 
a considerable portion of dead bone was removed from a cavity 
in the tuberosity, in which it was contained. The sinns which 
traversed the thigh had followed the course of the muscles arising 
from the tuberosity." 

Periostitis of the Trochanter has also been confounded 
with morbus coxarius. 

For convenience in study, the symptoms of these two diseases 
have been tabulated below : 

PERIOSTITIS OF FEMUR. THIRD DEGREE OF MORBUS COXARIUS. 

Mostly commences suddenly. Grows gradually out of preceding 

stages. 
Femur more or less enlarged. Not at all enlarged. 

Femur painful on pressure. Femur not painful in the least. 

Joint free. Almost fixed, and, when moved, often 

have crepitus. 
Extension and abduction impeded. The same. 
Joint painless. Joint painful on pressure. 

Pelvis oblique and spine curved. The same. 

Contraction of flexors and adductors. The same. 

The. following cases will further illustrate the distinctive feat- 
ures of the two diseases : 

Case. Periostitis of Trochanter and Upper Extremity of Fe- 
mur mistaken for Hip-Disease. — Hamilton L., aged nine, Clinton, 
Worcester County, Massachusetts, was brought to me October 2, 
1867, to be treated for diseased hip-joint. He had on at the time 
one of my short hip-splints, which he had been wearing for some 
months, but receiving no benefit his physician sent him to me to 
to see if anything further could be done. Inquiring into the 
history of the case, I found that he had been struck by a brick on 
the outer and posterior part of the right trochanter major, thrown 
by a boy. The pain was intense for a little while, but the next 
day he played as usual without pain, unless some one touched the 
outer part of the thigh at the place where he was struck. Some 
time after, he fell and struck the same place on a fire-dog or and- 
iron. About two months after he fell again in a heap of coal, 



340 



DISEASE OF THE JOINTS. 



and struck the same place with such violence as to cause in- 
tense pain, and from this time the inflammation and swelling 
commenced, which in three months resulted in abscess, which was 
opened by Dr. De Witt, U. S. A., just behind and below the 
trochanter major. This was about five months after the first 
fall. Dr. De Witt, as the father states, told him that the joint was 
all right, and that he could find no naked bone. This opening 
has continued to discharge up to the present time. Three months 
after the first opening another abscess formed and opened itself 
directly at the part where the first blow was received. Another 
a few mouths after opened on the front of the thigh about four 
inches below Poupart's ligament. 

Present Condition. — Very much emaciated, weighing forty- 
two pounds ; right thigh flexed and slightly abducted, but toes 
not everted as in second stage of hip-disease (as seen in Fig. 203, 
from photograph taken at the time). 




Fig. 203. 



The father states that the toes never were everted, but rather 
tended to turn in. At the present time they are not inverted or 
everted ; the limb is of the same length as the other, the big-toe 



CASE. 341 

touching the floor ; a hard, inflammatory swelling just above the 
tuber-ischii, which may probably terminate in another abscess. 
The knee is flexed at nearly a right angle (see figure), and fixed 
by fibrous anchylosis. The father says that previous to the first 
accident the boy was in perfect health, and very robust and 
active. 

Diagnosis. — Our diagnosis is periostitis of the trochanter 
major, with cellulitis and abscess around the joint, but not involv- 
ing the articulation. At this moment Dr. Gross, of Philadel- 
phia, happening to come into my office, I- asked him to examine 
the boy, who was still naked upon the table. He stated that it 
was a case of hip-disease " so well pronounced as to require no 
examination," but, after drawing his attention to some of its 
peculiarities, he immediately acknowledged his mistake. 

Treatment. — Leave off the splints and extension ; as the 
disease was not within the joint, no extension is required. 
Apply flax-seed poultice and open the abscess when necessary. 
Keep him out-doors and improve his general health by a nutri- 
tions diet ; make passive motions at the knee, and increase these 
movements as he can bear them. Directed to bring him back 
at the end of the month. 

I saw no more of this boy until September 22, 1868, when 
Mr. Lewis, his father, called to inform me that he was in per- 
fect health, and that my diagnosis had been correct, although 
upon his return to Massachusetts the year before, Dr. Warren, 
Dr. West, Dr. Bigelow, of Boston, and others, had still in- 
formed him that the disease was in the hip ; he, however, had 
followed my advice, applied motion to the knee, which was now 
straight, and all of its motions perfect. Motions in the hip were 
very greatly improved, but not quite so perfect as on the oppo- 
site side. One abscess had opened near the tuberosity of the 
ischium, but was now healed ; no bone had escaped. He now 
weighs fifty-eight pounds, and is in perfect health. 

Case. Periostitis of Trochanter Major, mistaken for Hip- 
Disease. — Kate B., aged eight, of Bridgeport, Connecticut. Her 
health has never been very good. Sixteen months since fell from 
a ladder ; one month later the disease began by pains in and 
around the knee, very similar to hip-disease. Condition, Septem- 
ber 10, 1867: Limb slightly atrophied; same length as the 
other ; no pain on pressure in the joint, but acute pain on press- 



342 DISEASE OF THE JOINTS. 

ure just below trochanter major. Motions of the joint not quite 
so free as the other. Flexion limited, very similar to hip-disease, 
but can adduct and rotate the limb inward, which cannot be 
done if the disease is within the joint. There is slight tenderness 
of nearly entire length of thigh on the outer side. 

Teeatment. — Rest, leeches, and then actual cautery over and 
behind trochanter major. 

June 15, 1871. — This patient presented herself with a per- 
fect hip, but has a large bursa behind the trochanter, which 
somewhat interferes with the motions of the joint. The mother 
thinks it is the result of a fall from a swing last autumn. She 
had been perfectly well for three years previous to the fall. This 
bursal sac was opened freely and soon healed, leaving her in per- 
fect health. 

With this case I received a note from the attending surgeon, 
in which he said that the limb was flexed and adducted in the 
early stage of the case. Now, this did not indicate hip-joint dis- 
ease, for the reason that flexion and adduction do not go together 
in the early stage. If the limb was flexed and adducted, it should 
be in the third stage of hip-disease, after rupture of the capsule 
has taken place. It was also stated that the toes were inverted. 
If effusion had taken place within the capsule, the toes must have 
been everted, unless rupture of the capsule had occurred. If 
rupture of the capsule had occurred, the limb should have been 
adducted, flexed, and the toes inverted ; therefore, the very fact 
that the limb was adducted said flexed, and the toes inverted dur- 
ing the early stages of the disease, was evidence that the difficulty 
was not in the hip- joint, but was the result of reflex muscular 
contraction. The periostitis had produced mnscular contractions 
which had developed distortions, and exhausting suppuration was 
also present ; but that peculiar distortion which would have been 
present had the disease been within the hip-joint, was not seen, 
and the result of the case proved my diagnosis to have been 
correct. 

Pott's Disease and Psoas Abscess may possibly be mistaken 
for hip-joint disease in the third stage. . The distinctive symptoms 
of the two diseases are here arranged side by side to aid in the 
differential diagnosis in the following table (from Bauer). The 
arrangement of the symptoms in this manner makes them more 
easy to remember. 



IXGUI^AL abscess. 3±3 

pott's disease axd psoas abscess. thied stage of moebus coxaeius. 

Preceding pain in the spine. Preceding pain in hip-joint. 

Posterior and anterior deformity (not Lateral and anterior deformity, 
always). 

Simple flexion and shortening of limb. Flexion, adduction, and inversion. 

Limb maybe extended under chloro- Cannot, 
form. 

Pelvis square. Pelvis oblique. 

Nates even. One higher. 

Cannot walk except by supporting the Can walk on well leg, and without 
spine by resting hands on the knees. these precautions. 

Abscess under Poupart's ligament. May have the same. 

Hip articulation free. Almost fixed. 

Slight retraction of flexors. Fixed contractions of both flexors and 

adductors. 

May have signs of paraplegia. Has none. Order of development, 

very different. If there is perfo- 
ration of the acetabulum, it may 
be ascertained by an examination 
through the rectum. 

Inguinal Abscess may be mistaken for the first stage of hip- 
joint disease. In inguinal abscess extension and abduction will 
increase the pain by bringing the inflamed parts under press- 
ure ; whereas, in the first stage of morbus coxarius, these move- 
ments will diminish the pain by relieving the inflamed parts 
from pressure. Pressure on the shaft of the femur, or on the 
trochanter, will increase the pain in the first stage of morbus 
coxarius, but will not necessarily do so in inguinal abscess. In 
inguinal abscess great pain will be caused by direct pressure 
upon the abscess itself. 

Inflammation of the Psoas Magnus and Iliacus Muscles 
may produce flexion of the limb, and there may be slight eversion, 
simulating the advanced first or commencing second stage of 
morbus coxarius. But pressing the head of the femur into the 
acetabulum, either from the knee or from the trochanter major, 
does not increase the pain, showing that the trouble is not in the 
joint. On the other hand, the pain is aggravated by extension, 
whereas in hip-disease extension affords relief. 

Congenital Malformation of the Pelvis, commonly known 
as " double congenital dislocation," may be confounded with hip- 
joint disease, as in the case now before you, which was sent to 
me to be treated for hip-disease. I object to the term congenital 



344 DISEASE OF THE JOINTS. 

dislocation, for the reason that we cannot with propriety speak 
of a dislocation until there has first been a location. Again, a 
real dislocation of the hip-joint in the normal pelvis, I believe, 
cannot be produced by the movements of the foetus in utero. It 
might be caused by the manipulations of the accoucheur, but in 
that case it could not be properly called spontaneous. 

The real difficulty in this condition, which has been termed 
congenital dislocation, but which I prefer to call congenital dis- 
placement, consists in the malformation of the acetabulum, 
namely, a non-fusion of the three bones which enter into its con- 
. struction. The cavity of the acetabulum being incomplete, the 
head of the femur rides through the opening left, and is found 
upon the dorsum of the ilium. Inasmuch, therefore, as the 
acetabulum has never really existed, in consequence of an arrest 
of development, there can, of course, be no dislocation from it. 
You might as well speak of the roof of a child's mouth with cleft 
palate. For the same reason reduction with retention is impos- 
sible, so long as the imperfection remains. The deformity, how- 
ever, is frequently mistaken for hip-disease, considering the rarity 
of the malformation. It is not difficult, usually, to arrive at a 
correct diagnosis in these cases, if the following points are care- 
fully considered : 

Congenital dislocation (dependent upon congenital malforma- 
tion) generally occurs in both hips ; morbus coxarius almost inva- 
riably occurs only in one. 

Congenital displacement is not attended with pain; while 
morbus coxarius is attended with extreme pain. In congenital 
displacement the deformity is peculiar, and differs essentially from 
that present in hip-disease. The breadth of the hips is very much 
increased, the pelvis is tilted forward and downward, the buttocks 
rounded out and elevated, making a very prominent hump when 
the patient is standing ; but, when he is placed in an horizontal 
position, and extension is made upon both limbs, the hump will 
disappear, and he will be elongated ; and then, by pressing up- 
ward upon the limbs, the hump can be made to reappear. If, 
while an assistant makes such extension and pressure upward, 
the fingers are placed over the trochanters, they will be found 
to glide up and down, like the lengthening or shortening of a 
telescope. If the finger is introduced into the rectum in young 
children, a distinct fissure in the plane of the ischium can be 



CONGENITAL DISPLACEMENT. 



3±5 



sometimes felt. In the adult pelvis the plane of the ischium 
will often be much wider than normal. The distance from the 
crest of the ilium to the trochanter major, when the limbs are 
pressed firmly upward, or when the patient is standing, will be 
shorter, as seen in Figs. 2(M and 205, than when the limbs are 
firmly extended, as seen in Figs. 206 and 207. 

Laying this child upon the table, we will first apply Nekton's 
test, which consists in drawing a line from the tuberosity of the 
ischium over the hip to the anterior superior spinous process of 
the ilium. This line passes directly over the top of the trochan- 
ter major if the head of the femur be in its socket and there is 
no fracture of the neck. In this case, even in so small a subject, 
we find the trochanter one inch and a half above the line. We 





Fig. 205. 



will next slip this piece of paper beneath the child, and pencil on 
it her form as she lies on the table, and now, pulling her out, 
see how we increase her length until her trochanter reaches my 
finger on ■ Nekton's line ; releasing our extension, and pushing 
against her feet, she goes together again — telescopes — like push- 
ing a pencil in its case, and the trochanter is nearly two inches 
above the line. Here, gentlemen, is the paper with the pencil- 



346 



DISEASE OF THE JOINTS. 



ing upon it — a drawing from life — and you can see the great dif- 
ference in her form in the extended and shut-up conditions. {See 
Fig. 208, from a sketch taken at the time.) 

In congenital displacement, motion is often perfectly free and 
painless, and ordinarily somewhat more extensive than normal ; 
while in morbus coxarius it is always limited, and always attend- 
ed with pain. 

Treatment, — In this child I propose to arrange something 
that will keep the limbs extended, and prevent their gliding up- 
ward, and also to put around the pelvic bones a compress which 
will assist in holding the heads of the femurs steady and approxi- 
mate the edges of the fissured acetabulum. 

I have seen a fissured palate in an infant, which involved the 





Fro. 206. 



Fro. 207. 



whole roof of the mouth, closed by means of compression. I 
operated upon this child when it was but three hours old, perhaps 
the youngest on record — by removing the proboscis, bringing the 
lips together, and applying over the malar bones a U -compress to 
gradually approximate the edges of the fissure ; and now, at the 
age of twenty-three, he has as good a roof to his mouth as any of 
you. It is this simple principle, gentlemen, that I propose to put 



TREATMENT. 



347 



in use in this child. It should have been done at birth ; but the 

child is jet young, and much benefit to it may still be anticipated. 

I have had made for this patient, by John Eeynders & Co., of 

309 Fourth Avenue, a double long hip-splint, capable of extend- 




Fig. 203. 



ing the limbs and permitting universal motion. It is applied the 
same as the hip-splint ; i. e., adhesive plasters are put on the legs, 
secured by a roller, with tabs sewed to their lower extremities, to 
which is attached the splint by means of buckles; a pelvis belt, 
hinged behind and clasping in front, goes around the ilii and 
perineal bands from the pelvic belt in front around the perineal 
folds, fastening to the belt behind. The instrument is extended 
by ratchet and key, and held in the extended position by a catch. 

By this instrument we can elongate the child, as you per- 
ceive by comparing Figs. 204 and 205 with Figs. 206 and 207, 
and, slipping down the catch, we hold her legs extended; she 
cannot shut herself up until some one touches the key. 

Do you see, gentlemen, how beautifully we can extend these 
limbs and hold them in their natural places ! With this instru- 



348 



DISEASE OF THE JOINTS. 



ment to keep the limbs extended, the compress to approximate 
the edges of the fissure, and a Darrach's wheel-crutch to give her 
out-door exercise, it is possible we may obtain a good result. In 
the course of a month or two the child will be returned to us, and 
we can then see what progress will have been made. 

Paralysis of the Lower Extremities, causing arrest of de- 
velopment, has been mistaken for hip-disease. 

This error I have seen occur several times. The first case I 
ever saw was sent to me by a distinguished surgical friend, for 
some hip-trouble. 

Case. Arrest of Development from Infantile Paralysis. — 
Julia H. E., aged nine, of Winchester, Tenn., of healthy parents, 
always in good health until she was twenty months old, when she 
lost the use of her right leg suddenly, waking up in the morning 
with total loss of motion and sensibility. Began to move her toes 
in about six months, and in a year dragged her foot after her, but 
would fall down about every third step. Condition as seen in 





Fig. 209. 



Fig. 210. 



Fig. 209, from a photograph taken August 27, 1867. Large 
and well-developed child, except right limb, which is four and a 
half inches shorter than the left, and small in proportion. Spinal 
column very much curved laterally at the junction of the dorsal 



INJURIES OF THE HIP. 349 

and lumbar vertebrae, the pelvis of the right side being much 
lower than the other. The case was sent to me as a case of luxa- 
tion of the femur, but I found it merely a case of arrest of develop- 
ment and atrophy, from infantile paralysis. There was slight 
contractility of all the muscles, showing that fatty degeneration had 
not taken place, but the difference in the length of the two limbs 
was the principal cause of her lameness. I applied to her shoe a 
sole and heel sufficient to equalize the length of the limbs, when 
her spine became perfectly straight, as seen in Fig. 210, and 
she was enabled to walk without a crutch or cane, by simply apply- 
ing India-rubber muscles, to take the place of the partially para- 
lyzed ones of the leg. Advised electricity, shampooing, and pas- 
sive movements. 

The treatment in this case was so entirely satisfactory that she 
left for home on September 15th, able to walk remarkably well 
with the aid of the rubber muscles and the increased length of heel 
to her shoe. The extreme curve that can take place in the spine 
to accommodate the difference in the length of the limbs is well 
shown in Fig. 205, and this case is also an instructive one in having 
been mistaken by so many eminent men for a case of hip-disease. 

Injuries, of the Hip may be mistaken for hip-joint disease. 
These include fractures, dislocations, diastasis, etc. 

Injuries of the hip can generally be excluded by the history 
of the accident which caused the trouble. The following differ- 
ential signs (from Bauer) will enable you to determine the ques- 
tion in case of doubt : 

Dislocation of Femur. 

ANTERIORLY AND SUPERIORLY. SECOND STAGE OF MORBUS COXARIUS. 

Suddenly produced. Comes on gradually, 

Extremity much everted. Less everted. 

Immobility. Immobility. 

Moderate shortening. Apparent elongation. 

Abduction. Abduction. 

Head can be felt in the groin. Head cannot be felt at all or very 

indistinctly, and then at the ace- 
tabulum. 

POSTERIOR SUPERIOR DISLOCATION. THIRD STAGE OF MORBUS COXARIUS. 

Produced suddenly. Growing gradually. 

Limb shortened and inverted. The same. 

Adducted. The same. 



350 



DISEASE OF THE JOINTS. 



Dislocation of Femur. — {Continued.) 



POSTEKIOR STJPEEIOE DISLOCATION. 

Immobility of articulation. 

Flexion of the hip. 

Moderate shortening. 

Head usually felt under gluteus maxi- 
mus. 

Apex of trochanter above Nelaton's 
line. 

No permanent contractions of mus- 
cles. 

Pelvis square. 

Walks with healthy leg bent. 

Touches ground with almost entire 
sole. 

Spine straight. 

Angle of inclination of pelvis un- 
changed. 



THIED STAGE OF MOEBUS COXAEIUS. 

The same. 

The same. 

Apparent shortening considerable. 

Head not felt at all. 

Below or even with Nelaton's line. 

Permanent contraction of flexors and 

adductors. 
Pelvis raised and oblique. 
Healthy leg straight. 
Only with the ball of the foot. 

Spine flexed laterally and anteriorly. 
Angle of inclination of pelvis in- 
creased. 



FEACTUEE AND DIASTASIS OF HEAD. 

Produced suddenly. 
Eversion of limb. 
Shortening of limb. 
Straight limb. 
Loose articulation. 
Straight pelvis. 
Crepitus in early stage. 
Spine vertical. 
Shoulders square. 

Nelaton's test (apex of large trochan- 
ter above the line). 1 



SECOND STAGE OF MOEBUS COXAEITTS. 

Growing comparatively slowly. 
Eversion and abduction of limb. 
Apparent elongation of limb. 
Flexed in hip and knee. 
Fixed hip-joint 
Oblique pelvis. 
No crepitus. 
Spine curved. 
One shoulder higher. 
Nekton's test (trochanter below the 
line). 



The impacted fractures are of course excluded in this collec- 
tion of differential symptoms. 

Diastasis of the Head of the Femur is frequently mistaken 
for Hip-Disease, as in the case now before you. 

This little girl was brought to me some time since, to be treat- 
ed for hip-disease, but I became satisfied, upon careful examina- 
tion, that she was not suffering from hip-disease, although she 
had been under treatment for that difficulty for a long time. 

1 Nekton's test (or Roser's test) is made by drawing a cord from the tuber-ischii 
to the anterior superior spinous process of the ilium, which will generally pass at the 
very apex of the trochanter major ; now, in fracture of the neck, or in true luxation, 
the apex of the trochanter will be found above this line. 



DIASTASIS. 351 

I was positive that there was no hip-disease in the case, and 
why ? There was a large abscess upon the hip, and there was 
evidently some trouble in that region, upon which this abscess 
depended ; consequently my examination was very much obscured 
by these attending conditions. But, upon close examination 
with reference to the beginning of the difficulty, I found that 
the accident which had occurred to this little girl had been fol- 
lowed immediately by shortening of the limb without going 
through the stages of abduction, eversion, and effusion of the sec- 
ond stage of hip-disease, and then the adduction and shortening 
of the third stage, which necessarily must have taken place had 
the case been one of hip-joint disease. 

In diastasis there may be adduction but not inversion, but 
these are invariably present in the third stage of hip-disease, ex- 
cept in extraordinary cases already mentioned. {See symptoms 
of third stage hip-disease.) 

Again, when I applied JSTelaton's test, which consists in draw- 
ing a line from the tuberosity of the ischium to the anterior su- 
perior spinous process of the ilium, the trochanter major was 
found above that line, which proved conclusively that there was 
either a separation of the head from the shaft of the bone, or a 
luxation. But the ordinary symptoms of luxation, inversion of 
the foot, etc., when the head of the femur is upon the dorsum of 
the ilium, were absent, and there was nothing left to account for 
the symptoms except fracture, or what is its equivalent in the 
young subject, diastasis. 

Again, in diastasis, after it has existed some time, concussion 
of the joint produces no pain, nor does crowding the head of 
the bone into the acetabulum by making pressure upon the great 
trochanter. The deformity which was present in the case was 
the result of an accident that had occurred two years before, and 
the abscess was caused by inflammation of the bursa over the 
great trochanter, and it was this abscess which had caused them 
to diagnosticate the case as one of diseased hip-joint. Diastasis 
had not been suspected, and, as the child moved about, the irrita- 
tion set up caused the psoas magnus and iliacus internus muscles 
to contract in such manner as to flex the thigh upon the trunk, and 
on this account the case was mistaken for one of hip-joint disease. 
But the flexion that takes place where diastasis occurs differs 
from that which results from disease in the joint. For, if the 



352 



DISEASE OF THE JOINTS. 



joint contains more than its normal quantity of fluid, the flexion 
is always accompanied by abduction and eversion, and, when the 
capsule becomes ruptured and the fluid escapes, the flexion is 
always accompanied by adduction and inversion, unless there are 
adhesions. 

In diastasis distortion is present, but it does not have that 
peculiarity which necessarily accompanies effusion. 

This little fellow you here see is a very good illustration of 




Fig 211. 



the deformity in cases of diastasis before any contraction of the 
muscles has produced flexion of the thigh upon the trunk. 

Case. — James H., three years of age ; parents healthy ; re- 
siding at 242 West Forty-seventh Street, New York. Child 
robust and strong. 

When three months old the child was rolled out of a cradle, 
and the mother, catching it by the leg while falling, felt some- 



DIASTASIS. 353 

tiling snap. Nothing particular was noticed until about a week 
after, when the mother states the hip looked somewhat swollen. 
He was taken to a physician, who said it was a simple sprain, and 
ordered soap-liniment, which was applied for eighteen months, 
with a bandage. He was then taken to St. Luke's Hospital, 
where it was pronounced hip-disease, and a weight and pulley 
was applied for six months, the child being constantly confined 
to the bed. No improvement occurring in his hip, and his gen- 
eral health becoming injured by confinement (his mother states 
that he is not so stout as when he went to the hospital), he was 
removed from St. Luke's and brought to Bellevue. 

His present condition is, as you see, tolerably good, although, 
as the mother says, he is not so fleshy as six months ago. The 
limb, as you observe, is shortened, adducted, and the foot very 
strongly everted. (See Fig. 211, from a photograph "by Mason.) 
In fact, you see it can be rotated completely around, so as to 
bring the toes behind. There is no pain on pressure in the axis 
of the limb, or over the trochanter ; consequently there cannot be 
inflammation within the hip-joint. There is very slight pain upon 
extreme rotation of the limb. In drawing a string from the 
tuberosity of the ischium to the anterior superior spinous process 
of the ilium (Nelaton's test), you observe that the top of the 
trochanter is above that line. 

Our diagnosis in this case is, therefore, diastasis, and not hip- 
disease, and that the separation, or fracture, if you choose to call 
it such, occurred at the time the mother seized it by the leg to 
prevent its falling when it was three months old. 

Treatment. — We shall put the extension-splint upon him, the 
same as if he had hip-disease, and thus prevent further contrac- 
tion and deformity, and to take the weight of the body on the 
perinseum, allow free motion to the parts, and thus aid in the 
formation of a new joint on the dorsum of the ilium. 

Case. Diastasis of the Head of the Femur. — E. M. J., 
female, aged four years, was brought to me on January 5, 1873, 
with the following history : 

On Christmas, 1870, being then twenty months old, and a 
very active, robust child, and having walked for six months, was 
left by her mother for about two hours in charge of the nurse. 
On her return the child was found lame in the left leg, which was 
shortened and slightly turned out, and has not been able to walk 
23 



35± 



DISEASE OF THE JOINTS. 



upon it or touch the floor since. The nurse insisted with great 
positiveness that she had received no fall or other accident during 
the mother's absence, and that she had not been out of her sight 
a single moment. The child being too young to contradict this 
statement, it has to be received for what it is worth. 

As the parents were then living in London, the child was 
carried to the different hospitals, according to the mother's state- 
ment, and examined by various surgeons, who pronounced it a 
case of hip-disease, and advised leeching, blistering, and rest. 
The limb gradually contracted, adducted, and rotated, until in 
the course of a year it assumed its present condition (as seen in 
Figs. 212 and 213, from photographs by O'Neil), which it has 
retained until the present, time. 





Fig. 212. 



Fig. 213. 



The parents came to America in 1872. The child was taken 
to two of the public institutions of this city, where the trouble 
was pronounced to be hip-disease far advanced in the third stage. 
She was then sent to me to have exsection performed. 

Upon examination I found her to be a very robust and re- 
markably healthy child, and born of healthy parents. Upon strip- 
ping the child and laying her upon the floor upon her back so 



DIASTASIS.— CASE. 355 

that the spinous processes would touch the surface, while at the 
same time a line drawn from the centre of the sternum over the 
umbilicus to the centre of the symphysis pubis was crossed at a 
right angle by a line drawn from the anterior superior spinous 
process of one ilium to that of the other. In this position, the 
pelvis and trunk being held in their normal relations, the right 
thigh could be extended straight with the body until the popliteal 
space touched the floor, while the left was standing at a right 
angle with the body, slightly adductedand rotated outward nearly 
one-half upon its axis, so that the heel was pointing in a line over 
the right shoulder, and the foot in the opposite direction, as seen 
in Fig. 213. 

In this position the limb was fixed and apparently anchylosed. 
There was no pain or tenderness around the joint upon the most 
severe pressure, and the mother said that there had not been for 
a year past. The child would bump herself along the floor upon 
her bottom and the foot of the well limb, as fast as most children 
would creep, her arms being used as crutches, and this was her 
mode of locomotion. When standing up the thigh was at a right 
angle with the pelvis, adducted across the upper third of the op- 
posite thigh. The back was strongly curved at the sacro-lumbar 
junction, but not sufficiently to enable the foot to touch the floor. 
(See Fig. 212.) 

There has been no suppuration about the joint, abscesses, or 
other evidences of carious disease of this articulation. The promi- 
nence in the gluteal region which had been mistaken for an 
abscess was caused by the trochanter major, which upon examina- 
tion was found an inch above the line of Xelaton's test, indicat- 
ing that there was either a fracture or luxation. The outward 
rotation of the foot contraindicated luxation on the dorsum of 
the ilium, and there was therefore nothing left in the diagnosis 
but fracture through the neck, or its equivalent in a young sub- 
ject, diastasis, or separation of the head from the neck at its epi- 
physeal junction. 

The suddenness of the occurrence, the entire history of the 
case, and its present condition, confirmed this opinion. The child 
was placed under chloroform, and with some force limited move- 
ments could be obtained, showing that anchylosis had not occurred. 

A pair of wire breeches were ordered for her ; and on January 
22, 18T3, at Belle vue Hospital, in the presence of the class, I put 



356 



DISEASE OF THE JOINTS. 



her under chloroform, and subciitaneously divided the adductor 
longus, gracilis, and tensor vaginae femoris muscles, closed the 
wounds with adhesive plaster, and with some little force broke up 
the adhesions, and brought the limb parallel with the other and 
nearly of the same length. She was then placed in the " wire 
cuirass," which had been well padded, the well limb straightened 
so as to bring the foot firmly against the foot-piece, while the 
anus had been secured in its proper place for defecation. This 
limb was then secured by a roller from the foot up, with a piece 
of pasteboard over the leg and thigh, to keep the knee from bend- 
ing, so as to make that limb a solid column against the foot-board 
for counter-extension. 

The deformed limb was dressed by placing strips of adhesive 
plaster on each side from just above the ankle to the middle of 
the thigh, and secured by a well-adjusted roller from the foot up, 
leaving a few inches of the plaster on either side of the lower ex- 
tremity, to be pinned around the foot-board, which latter had been 





Fig. 214. 



Fig. 215. 



screwed up to meet the shortened limb. A few turns of the 
screw readily brought the limb down to the desired length, and 
it was secured to the other leg of the wire cuirass by a roller, and 
the dressing was complete, as seen in Fig. 214. 



DIASTASIS.— CASE. 357 

She was sent home to her boarding-house in a little hand-car- 
riage, and went out riding every day, notwithstanding the in- 
clement weather, without the slightest inconvenience. She re- 
turned to the hospital on January 29th. The wounds had entirely 
healed without suppuration, only a very slight ecchymosis existing 
around the puncture over the tensor vaginae femoris. She was 
redressed completely, with the exception of the plasters upon the 
extended limb, the limbs washed, passive movements given to all 
the joints, and replaced in the wire cuirass for another week. 

February Mh. — Applied long extension-splint with abduction- 
screw, when she was able to walk with the assistance of a cane. 
The limb could be extended to very nearly the normal length. 

She wore the extension-splint for nearly fourteen months, when 
she had entirely recovered with scarcely a half -inch shortening of 
the limb, which was easily rectified by increasing the heel of her 
shoe, and the motions of her hip-joint so nearly perfect as not to 
attract attention. 

Fig. 215, from a photograph taken eighteen months after the 
operation, shows her present condition. This photograph was 
taken at Poughkeepsie, her present residence, and the operator 
had made the focus such as to represent her as much smaller than 
in the other pictures taken eighteen months before, but Mr. 
Bross has preferred to copy it exactly, rather than to enlarge it to 
correspond with the others. 

Here is a specimen (Fig. 216) which illustrates most beauti- 
fully what takes place in the disease or accident we are now con- 
sidering, both in the change in the % original acetabulum, which is 
nearly obliterated, and also in the formation of a new joint upon 
the dorsum of the ilium, which is almost as perfect in form as 
the original acetabulum. 

The little fellow from whom this ilium was removed was 
brought to me in 1860 by his physician, for the purpose of having 
his hip-joint exsected, as he was supposed to be suffering from 
disease of that articulation in its advanced third stage. He was 
then six years of age, and presented a most singular deformity, 
different from any I had ever seen at that time. 

He was quite a robust and healthy-looking boy, without the 
haggard and cachectic look of most cases of advanced hip-disease, 
and I was therefore led to scrutinize him with more than ordinary 
care. His thigh was flexed at nearly a right angle with the pelvis, 



358 DISEASE OF THE JOINTS. 

and adducted across the median line, and fixed in this position ; 
but the foot was most strangely everted and rotated outward, so 
that the heel presented in front. His position was very similar 
to that in Figs. 212 and 213. There was no pain or tenderness 
upon pressure, and to my mind there were none of the indica- 
tions of hip-joint disease present. 

The physician who brought him to me had only seen him a 
short time before, and knew nothing of his previous history, but 




Fig 216. 



supposed it to be a case of advanced hip-disease on account of the 
deformity and his inability to move the limb, although he had 
never carefully examined him. 

Upon making careful inquiry of his parents and the physician 
who had first seen him, I learned that he had fallen down the 
cellar-stairs two years before (when he was four years old), and. 
that when the doctor saw him, on the following day, his foot was 
already turned outward and his leg shortened and adducted, very 
similar to Fig. 211, and he considered it a case of fracture or 
diastasis of the head of the femur. 

The child suffered so little that the parents were inclined to 
doubt the correctness of the doctor's diagnosis, and dismissed him. 
Another physician was called in, who pronounced it to be a simple 
sprain, and that it was of no importance. 

The child began to hop around in a few weeks, but could 
never bear any weight upon the foot. In a few months the thigh 



ARTIFICIAL ACETABULUM. 359 

began to draw up, and finally became fixed in its deformed posi- 
tion, about one year before lie was brought to me. 

Having obtained this information of its early history, the case 
was clear, and the diagnosis easy, namely, diastasis, with result- 
ant muscular contractions and fibrous anchylosis. 

The treatment was, to divide the contracted tendons and bring 
the limb into the straight position by force. When the wounds 
caused by the tenotomy had healed, a long splint was applied, 
which he wore for about two years, and finally recovered with 
almost as complete motion as in the normal joint. The boy died 
of double pneumonia in 1868, and the attending physician was 
kind enough to allow me to make a post-mortem examination, 
when the specimen (Fig. 216) was obtained. 

We have here a natural ilium, and upon it an irregular ace- 
tabulum, B, triangular in shape, in which what is left of the old 
head of the femur remains. Just below this point, upon the 
plane of the ischium, there is a little round facet, A, something 
like the facet upon the vertebrae for articulation with the head of 
the ribs, which is the point where the end of the femur rested 
before I saw him, and when the leg was flexed at nearly a right 
angle with the body. By cutting the tendons and allowing the 
limb to come down, and by the use of the instrument, eventually 
a new acetabulum, (7, was made, which is upon the dorsum of the 
ilium, and has a crescentic edge so as to make a more perfect 
shoulder for the femur to rest against. 

This new acetabulum, when rubbed with another piece of 
bone, gives the same feeling as when this is done with two pieces 
of ivory rubbed together. It is exactly such a sensation as is 
felt when the femur is moved in the acetabulum of the little 
patient who has just gone out. 

This acetabulum was surrounded by a new capsular ligament, 
and the new formation performed all the functions of a normal 
joint, although there were no articular cartilages, synovial mem- 
brane or ligamentum teres. So far as usefulness was concerned it 
was just as good as a normal joint, being a perfect specimen of 
eburnation. 

The treatment which I adopted in all these cases was, first to 
divide such tendons and fasciae as were necessary to permit the 
limb to be brought into the straight position, and then apply an 
instrument which is a modification of Taylor's long splint. 



360 DISEASE OF THE JOINTS. 

In the case of the little girl who has just gone out, the ab- 
ducting and inverting screws were also necessary. (See Fig. 171.) 

These instruments and their mode of application have already 
been described. (See lecture on Hip-disease.) 

In those cases of diastasis, however, in which there is no con- 
traction of the tendons, and the limb can be restored to its normal 
position, the long splint should be immediately applied, and worn 
until recovery has taken place. If you are called to attend the 
case immediately after the occurrence of the accident, treat it 
precisely as you would a case of fracture of the thigh, and place 
the patient at once in the wire cuirass, plaster-of-Paris dressing, 
or other apparatus, which will hold the parts perfectly quiet. I 
prefer the wire cuirass, especially for small children. 



LECTUKE XXV. 

DISEASES AND DEFORMITIES OF THE SPINE. POTt's DISEASE, OR 

ANGULAR CURVATURE. 

Definition. — Anatomy of the Spinal Column. — Etiology. — Pathology. — Symptoms. — 
Method of examining the Case. — Treatment. — Mechanical Appliances. — Plaster- 
of-Paris Jacket. 

Gentlemen: To-day we have to speak of deformities of the 
spine, and of the diseases which produce them by affecting the 
bony structure. Deformities of the spine may be a consequence 
of disease either of the bones and cartilages, or the result of irregu- 
lar muscular contraction, and the important point in their study 
is, to arrive at the pathological changes that have given rise to 
them. 

Of these deformities there are two: 1. The one known by 
the name of Pott's disease, or posterior angular curvature, in which 
there is destructive inflammation of the bones, accompanied with 
loss of substance in the bodies of the vertebrae and intervertebral 
disks ; 2. The deformity known as rotary lateral curvature of the 
spine, in which there is no disease of the bones, but the distortion 
depending entirely upon irregular muscular contraction. 



POTT'S DISEASE. 361 

The one is distortion, the result of destructive inflammation 
of the bones and intervertebral substance ; the other is distortion 
dependent upon irregular, abnormal muscular contraction. Some- 
times the distortion produced by this action of the muscles very 
closely approaches in degree and appearance that present when 
the bones and cartilages are diseased, and is then occasionally mis- 
taken for Pott's disease. (See Fig. 230.) 

The posterior angular curvature, or Pott's disease, will first 
engage our attention. You will recollect that the spinal column 
is made up of twenty-four bones and twenty-three intervertebral 
cartilages, independent of the sacrum and coccyx. The bones or 
vertebrae are made up of a body, processes, etc., which in early 
life are separate, being developed from distinct points of ossifi- 
cation; and complete fusion does not take place until life has 
become considerably advanced. The bodies of the vertebrae have 
a soft spongy texture, while the processes and articulating facets 
are more dense and firm. The bodies, being spongy, are much 
lighter and are much less frequently fractured than bones of 
denser structure ; they are also much better adapted to receiving 
concussion without injury. At the same time the force of concus- 
sion is broken by the intervening cartilages, which are also spongy 
and elastic, and in this manner shocks are dissipated which would 
otherwise be transmitted to the brain, when a person comes down 
firmly upon the pelvis or feet. The intervening cartilages are 
like the rubber buffers under the railway-cars, and are so elastic 
that when pressure is removed from them they will return to 
their original dimensions. This is a practical fact that can be 
demonstrated by measuring a man in the morning before he gets 
up and again at night after he has been upon his feet all day ; 
when it will be found that he has shortened from one-fourth to 
one-half an inch, which loss will be restored when he has had 
a certain number of hours' rest in the horizontal position. JSTow, 
there is a disease that occurs in the vertebral column which is 
called Pott's disease. It may occur at any period of life, but is 
much more likely to occur in childhood, and especially in those 
children who are reckless and careless, and expose themselves to 
all sorts of accidents. It also occurs more frequently among boys 
than among girls, because they are more exposed to accidents ; 
whereas the lateral curvature is seen more frequently among girls. 
With regard to this affection, I have arrived at the conclusion, 



362 DISEASES AND DEFORMITIES OF THE SPINE. 

based upon an accurate and carefully-recorded experience, that it 
is produced almost always, if not always, by some injury to the 
bone or cartilage, and is hence traumatic in its origin. 

By the profession in general, Pott's disease, above all others, 
has been considered as essentially of strumous origin ; as depend- 
ing upon a tuberculous diathesis, and not occurring unless consti- 
tutional dyscrasia is present ; but, in my own judgment, it much 
more frequently depends upon some injury than upon any consti- 
tutional condition. The very fact that hundreds of people are 
walking about distorted, in many cases to a great degree, and yet 
remain in this condition and enjoy an average degree of health, 
until they have reached a good old age, is evidence that the dis- 
ease which has produced the deformity is not tubercular in char- 
acter. 

The accidents which produce this disease are usually concus- 
sions and blows. Those children who are usually full of play 
may in some of their careless pranks jump from some height, and 
come down straight without bending the knees or hips, thereby 
giving a sudden and severe concussion to the bodies of the verte- 
brae and their intervertebral disks of cartilage, and in this manner 
disturbing some centre of ossification to such an extent that in- 
flammatory action follows, and the case terminates in inflamma- 
tory softening and disintegration of the bone itself. Many times 
direct blows are received which are suflicient to injure the bones 
and give rise to subsequent trouble of a serious character. It 
sometimes happens that even the transverse processes of the ver- 
tebra become fractured, and the injury passes unsuspected and 
unrecognized, and is accidentally found at post mortem or in the 
dissecting-room. 

After such disturbance or separation of one or more ossific 
centres of the vertebrae, several months may elapse before atten : 
tion is drawn to the case, and perhaps by that time the bones 
have been partially destroyed and the distortion developed. Then 
it is said at once that the exhausted condition which may be 
present is evidence of constitutional cachexia, whereas it is simply 
the result of long-continued suffering from a local disease depend- 
ent upon some direct injury to the parts involved. 

Abscesses, commonly known as psoas or lumbar abscess, are 
quite frequently developed in connection with this disease, and 
the pus formed among the diseased vertebrae becomes imprisoned 



POTT'S DISEASE. 363 

by the fibrous tissue with which it is surrounded, and does not 
reach the surface, in many cases, as in an ordinary abscess, but must 
travel along under the sheath of the tendons until it reaches the 
point where psoas abscesses usually show themselves. This may 
require a long time, and give rise to serious constitutional disturb- 
ance. In some cases these abscesses penetrate the tissues and 
present themselves between the ribs. When the disease has ad- 
vanced so far that inflammatory softening and degeneration of 
the bone are present, the weight of the body upon the inflamed 
and degenerating parts will cause absorption to take place, which 
will go on most markedly upon the anterior portion of the bodies 
of the vertebrae ; and, as they lose their thickness at this point, 
the bodies fall together, and this causes the spinous processes to 
assume a peculiar-shaped prominence, which has given rise to the 
name posterior angular curvature. 

Symptoms. — The symptoms of this disease vary according to 
its location in the spinal column. When it has advanced far 
enough to produce a deformity, there is usually no difficulty in 
diagnosis. It may be present, however, long before any deformity 
becomes developed, and the important point is, to be able to rec- 
ognize it at that early period. The symptoms, at the beginning, 
are sometimes very obscure ; but the nerves that make their exit 
from the spinal canal at points opposite to the seat of the disease 
become more or less involved, and will manifest such disturbance 
by symptoms developed at their distal extremities. For instance, 
if the disease is situated in the cervical region, long before any 
distortion appears the patient will complain of difficulty in swal- 
lowing ; many have a choking sensation as if there were a string 
around the neck ; difficulty about the larynx, producing an irri- 
table and continued cough ; pain in the thorax, etc. Such symp- 
toms may be the only ones present that will attract attention ; but 
they are sufficient to arouse your suspicions, and, if you cannot by 
means of the laryngoscope and physical examination of the chest 
detect any disease of the larynx or lungs, or any of the thoracic 
organs, sufficient to account for the symptoms present, you should 
at once make a thorough examination of the spine. 

When the disease is in the dorsal region the patient very often 
complains of pain in the lower part of the chest and upper part 
of the abdomen ; also a constricting sensation as if a band were 
around the body; complains more or less of indigestion and 



364 DISEASES AND DEFORMITIES OE THE SPINE. 

flatulence, and may have been treated for dyspepsia. He may 
also complain of pain in the chest, pain about the heart, and per- 
haps may have been treated for rheumatism. 

Again, when the disease is lower down in the spinal column, 
he may have a sense of constriction about the abdomen, may suffer 
from constipation and flatulence, and perhaps have been treated 
for worms. 

When the disease is still lower in the spine, the leading symp- 
toms may be those referable to the bladder and rectum. The 
chief symptom in the case may be a frequent desire to pass the 
urine. Then the patient may also suffer from streaking pains 
down the thighs. 

When such symptoms are present, and they cannot be ex- 
plained by the presence of some well-recognized disease, always 
go back to the point where the nerves distributed to these regions 
make their exit from the spinal canal, and carefully examine the 
bony structures which surround them. 

Early in the progress of the disease reflex contractions are 
excited among the muscles, which result in a change in the 
appearance and action of the child, that is worthy of special 
attention. 

Every joint of the lower extremities is bent for the purpose 
of preventing any concussion from affecting the bodies of the 
vertebrae. The chin is made to project; the shoulders become 
elevated ; and it is impossible for the child to stand upright and 
receive any concussion whatever which may be communicated to 
the bodies of the bones without suffering pain. The muscles of 
the back are held rigid, in order to prevent any movements of 
the bodies of the vertebrse upon each other. The child is unable 
to stoop down and pick up any object upon the floor ; but, if 
asked to do so, he begins by bending his hips, and then his knees, 
and finally reaches the object by squatting down to it. These 
patients never bend the back, for bending the back presses the 
bodies of the vertebrae together, and gives rise to pain ; conse- 
quently all the movements of the child are directed in such a 
manner as to prevent any motion in the spinal column. 

When walking about the room, the child will reach with his 
hands from one article of furniture to another, making careful 
calculation that he shall not be deprived of the support furnished 
by one article before he receives support from another. If he 



HOW TO EXAMINE THE SPINE. 365 

. cannot obtain any support by catching bold of various articles 
within reach, he will rest his hands upon his thighs in order to 
transmit the weight of the head and shoulders through the legs 
to the ground, thereby giving them support without bearing upon 
the diseased vertebras. The patient instinctively makes every 
position which he takes serve to lift the weight of the shoul- 
ders and head from a spinal column which is in a state of disease. 
"When, therefore, a case presents itself in which the patient com- 
plains of cough, indigestion, disturbances about the bladder or 
rectum, or constant and persistent pain in the chest or abdomen, 
and you are not able to detect any disease of the lungs, stomach, 
liver, or other organs which will account for the development of 
such symptoms, I have to repeat to you again, do not fail to 
examine the spine. The question now arises, How is this to be 
done ? In the first place, put some object upon the floor and ask 
the child to pick it up, and then carefully note the position he 
assumes while performing the act. If the vertebras are diseased, 
he will squat down and pick up the object in the manner just 
described, and rise up in the same careful way that he went down, 
keeping the back as nearly straight as possible, and allowing no 
movements in the spinal column which he can prevent. He 
never bends over like a healthy child, but keeps his spinal col- 
umn as free from movement as possible. 

You will then strip the child naked and lay him across your 
lap, face down, with the arms over one thigh and the legs over 
the other, and then gradually separate your thighs. When that 
is done, the first thing you will notice, probably, will be that the 
child takes a long breath, a long-drawn sigh of relief ; and this 
leads me to speak of another symptom which I have omitted to 
mention. When the child is walking about, particularly if the 
disease is in the dorsal or lower cervical region, he breathes in a 
short, grunting manner, because of the constant effort on the 
parts of the muscles to hold the trunk still. In other words, 
there is a constant effort to put a muscular splint on the child's 
body to prevent motion in the spinal column, and thus the child, 
by his short, grunting breath and muscular rigidity, is trying to 
teach us doctors what the indications for treatment are in his 
case. The pressure upon the intercostal nerves is sometimes so 
great as to produce almost spasmodic respiration. Now, by 
placing the child across the lap in the manner described, and 



366 DISEASES AND DEFORMITIES OF THE SPINE. 

then making gradual extension npon the spine by separating 
your thighs, thereby relieving the nerves of all pressure and the 
muscles from all irritation, the first thing that will be noticed is 
this long sigh of relief — a full inspiration and complete expira- 
tion. As long as the child is held in that manner, he will be per- 
fectly comfortable and breathe easily, if you do not carry the 
extension so far as to produce reflex muscular contraction. Then 
close the limbs again, and the muscles are at once excited to con- 
tract, and the child again begins his short, catching respiration. 

There may be more or less spasmodic muscular action all over 
the body when the extension is removed ; but, if there is not, it 
can be very easily developed by placing one hand upon the head 
and the other over the bottom of the sacrum, and crowding the 
bodies of the vertebra together. The instant that is done, you 
will see a spasm, probably of both legs and arms, and the child 
will cry out on account of the pain ; and, the moment extension 
is made, he is all easy again. 

Now, all this can be done when the disease is in the anterior 
part of the oodles of the vertebrae, or in the intervertebral disks ; 
but it may be, in the case which you are examining, that the 
anterior bodies of the bones and the disks have not yet become 
involved, and yet the child is suffering from Pott's disease. For, 
when the dorsal portion of the spinal column is affected, the dis- 
ease does not always expend itself upon the anterior portion of 
the bodies of the vertebrae at first, but the part most extensively 
involved may be upon the sides of the vertebrae, where they form 
a junction with the ribs. 

In these cases the blow or injury is generally received upon 
the sides of the body, and the heads of the ribs are driven against 
the vertebrae with such force as to give rise to a starting-point 
for an inflammation. Consequently you must not be content with 
examining the spinal column, as far as the bodies of the verte- 
brae alone are concerned, but you must test the sides of the verte- 
brae by pressing the heads of the ribs against their articulating 
facets. Very frequently you will not be able to develop any 
symptoms of spinal disease, until you press upon the ribs in this 
manner. You may be able to press the spine down without pro- 
ducing pain ; percuss the spine without producing pain, and the 
spinal column may apparently be straight, all of which might 
lead you to the conclusion that it is not diseased ; but pressure 



EXAMINATION OF SPINE. 367 

upon the ribs, which will bring their heads in contact with the 
articulating facets, gives the patient pain, and at once you have 
evidence of diseased vertebrae. By pressing upon the ribs sep- 
arately in this manner, the exact location of the disease can be 
determined. 

When the child is placed across the lap, and extension is 
made, a moderate downward pressure upon the spinous processes 
will make them more comfortable, because it removes the press- 
ure from the anterior portion of the bodies of the vertebrae. 

The fact that pressure can be made over the spinous processes 
without causing pain is regarded by many as evidence that no 
disease of the bones is present. But it is the anterior portion of 
the body of the vertebrae that is affected, and, when these begin 
to give way, the spinous processes begin to stick out, and by 
crowding upon them we remove the pressure from the diseased 
surfaces, and consequently the suffering of the patient is dimin- 
ished. There is another item in the way of examination that 
may be of service to you in making out obscure cases, and that is 
the use of ice and intense heat. There are some cases in which 
no definite symptoms can be obtained by examining the patient in 
the manner described. In such cases the application of ice or in- 
tense heat may be of service ; for the nerves made irritable by 
the disease will receive impressions much quicker than they do 
normally, so that when a piece of ice, or a vial or thimble con- 
taining hot water, is passed along the spine, no response is ob- 
tained until the point opposite the disease is reached, when there 
will be a sudden move of the body as if to get out of the way of 
the irritant. In this manner you will sometimes be able to spell 
out cases which cannot be easily explained in any other way. 
And also by the delicate surface thermometer, recently devised 
by Dr. Seguin, of this city, you will be able to detect an elevation 
of temperature over the inflamed part that you could not discover 
in any other way. 

Partial or complete paralysis, of one or both lower extremities, 
sometimes occurs during the progress of Pott's disease, but occurs 
more especially when the disease is in the lower portion of the 
spine, so that the nerves which are given off to supply the lower 
extremities become involved. It depends either upon effusion 
into the cord, or pressure upon it by the distortion of the bones, 
and in the first instance will gradually improve, as absorption of 



368 DISEASES AND DEFORMITIES OF THE SPINE. 

the effusion takes place ; but, in the latter instance, prognosis, so 
far as restoration of power is concerned, is very unfavorable. 

As to the theories relating to this form of disease, I think it 
hardly worth while to consume your time in discussing them, for 
you can read them at your leisure in all the text-books upon 
surgery. I simply wish to make these points : that it is the result 
of injury in almost all cases; that this injury is followed by 
inflammatory action; that it can be diagnosticated by making 
extension and counter-extension upon the spine, and by pressure 
upon the sides of the vertebrse ; also by symptoms referable to 
the distal extremities of the nerves involved in the disease, long 
before the deformity is produced; and being detected in this 
early stage, can frequently be cured without any deformity oc- 
curring. 

Mistakes need not be made in diagnosis, and it is also of the 
greatest importance that the disease should be detected early, 
before deformity appears, for, once having taken place, it is 
generally irreparable. This brings us to the subject of treat- 
ment. 

Treatment. — In the earlier stages (and it is during this 
period that treatment is most important) there is nothing which 
can compare with rest, absolute and complete, in the horizontal 
posture. For pressure upon the parts diseased, when the patient 
is in the upright posture, causes more rapid softening, degenera- 
tion, and absorption, and in this manner a permanent deformity 
may be very rapidly developed, such as you see in the specimens 
before you. {See Figs. 217 and 218.) 

If the disease is situated low down, as in the lumbar region, 
rest in the horizontal posture is especially required. If it has 
progressed far enough to produce any distortions, you will be 
obliged to prepare a bed that can accommodate itself to the pro- 
jecting spinous processes. This indication is met by either the 
air or water bed; but I prefer the air-bed, because it can be 
emptied and filled with much less trouble. When you have 
placed your patient upon one of these beds, if there be tenderness 
along the spine, or any evidences of active inflammation, ice along 
the spine, by means of ice-bags placed upon either side opposite 
the seat of the disease, will be of the greatest service. If the pain 
is acute, a half-dozen leeches may be applied, and repeated every 
eight or ten days, and then followed by the ice-bags. If the skin 



POTT'S DISEASE. 



369 



is too sensitive to the influence of cold to bear the immediate 
contact of the ice-bags, a few thicknesses of muslin may be inter- 
posed. 

But rest is the great feature of the treatment. You must 
remove all pressure upon the parts involved, and the best possible 





Fig. 217. 



Fig. 218. 



manner in which that can be done is to place the patient in the 
horizontal posture upon a water or air bed. 

At best, however, it will take a long time for these patients 
to get well ; therefore some means must be devised which shall 
not only afford the benefit derived from rest, but at the same time 
permit them to have the benefit of fresh air and sunlight. This 
can be accomplished by placing the bed upon wheels, so that it 
can be rolled about to suit the convenience of the patient Another 
excellent method for accomplishing the same thing is, to dress the 
patient in the wire cuirass ; in other words, make this apparatus 
take the place of the bed. In order that the cuirass maybe worn 
with ease and comfort, I have an India-rubber bed made to fit the 
instrument accurately, and this is filled with air, and makes an 
elastic cushion for the patient to lie upon. Of course you must 
not forget, while using this dressing, to remove the patient oc- 
casionally, and give free movements to the joints of the lower ex- 
tremities, lest anchylosis take place. 
24 



370 DISEASES AND DEFORMITIES OF THE SPINE. 

Give your patient all the good food that he can properly 
assimilate ; and doubtless he will also require some remedies to 
regulate the' stomach and bowels, and invigorate the appetite, 
such as some of the ordinary stomachics and tonics, and perhaps 
a little champagne or brandy. Cod-liver oil, cream, milk, are all 
serviceable ; in short, everything should be done which is of pos- 
sible service in building up the system. These measures are re- 
sorted to, not with the idea that there is constitutional taint to be 
overcome, but because it is .the only way in which the system can 
be brought into the condition which best favors the process of 
repair. 

Blisters, issues, and setons, applied for the purpose of keeping 
up a long-continued counter-irritation and discharge, are positively 
injurious, and under no circumstances whatever should such 
measures be adopted ; but the actual cautery, applied as near the 
diseased vertebrse as possible, will, by its stimulating action on the 
deep-seated vessels, be of the greatest service ; but when this is 
used always allow the wound to heal before it is reapplied, and 
never keep open a running sore. In the first place, the child is 
already sufficiently disturbed and prostrated by the pain attend- 
ing the disease, without tormenting him any more by agents 
which, from their very nature, will produce pain ; and he is also 
already sufficiently emaciated, without establishing a suppurative 
process to make him more so. 

Best in the horizontal posture, and continued until you can 
bring the diseased surfaces of bone together without producing 
pain, is the only safe rule to guide you in giving the patient per- 
mission to assume the upright posture. When he is permitted to 
assume this posture, it must always be attended by some artificial 
support which shall remove all pressure from the bodies of the 
vertebrse. This can be given by straightening the spinal column 
in such a manner that the weight of the body is borne by the 
transverse processes, and not by the bodies of the vertebrse, for 
these processes, having a denser structure, can bear pressure with- 
out much danger of producing erosion. 

For this purpose, Dr. C. Fayette Taylor, of this city, has de- 
vised a brace which possesses some elements of great practical 
value. The important feature of the instrument is the hinge- 
motion, afforded at a point opposite the disease in the vertebral 
column, so that the weight of the upper portion of the column 



SPINAL SUPPORTS. 



:71 



can be transferred from the bodies of the vertebrae to the trans- 
verse processes. (See Fig. 219.) 

The idea involved in the construction of some instruments, 
namely, that of lifting the bodies of the vertebrae apart by placing 
a belt about the hips, and a support under the arms, is simply 
absurd, because the mobility of the scapulae is so great that they 
can be lifted up, as far as the endurance of the patient will permit, 
without relieving the weight of the body upon the spine. In fact, 
this can only be done by an accurately-fitting apparatus applied to 
the body itself when extended, like the plaster-of-Paris jacket 
which I have recently used. 

If the disease involves the cervical vertebrae, an additional 
support to the head can be given by the use of Dr. Davis's instru- 




Fig. 219. 




ment for that purpose. (See Fig. 220.) This consists of a steel 
rod (Z>), running over the head and resting on two shoulder-caps 
(G, G\ which are well cushioned, and retained in place by being 
attached to a pelvis-belt by a rod (B), in front and rear of the 
body. From the top of the rod is suspended, by an elastic band, 



372 DISEASES AND DEFORMITIES OF THE SPINE. 

the wire (F\ to which is attached an inelastic webbing running 
under the chin and occiput. And, by making the elastic at the 
top longer or shorter, the cervical vertebrae can be extended at will. 

If you are not able to obtain any of the apparatus described, 
you may take a piece of ordinary sole-leather, dip it into cold 
water until it becomes perfectly soft and flexible, and, after the 
child has been straightened out as much as can be done with 
safety, mould it upon the body, and secure it by means of a roller- 
bandage. 

Again, they may be dressed with plaster of Paris, as you would 
a fracture. 

The thought had occurred to me that this might be done, but 
I had hesitated through fear that respiration would not be prop- 
erly sustained if the child were completely enveloped in such a 
fixed apparatus. 

However, a child, four years of age, was brought to my office 
six weeks since, from the country, with Pott's disease, or pos- 
terior angular curvature of the last two dorsal and first lumbar 
vertebrae, unable to stand, very much emaciated, and the right limb 
paralyzed — probably from the pressure upon the spinal cord. The 
child had suffered the usual symptoms of this disease for more 
than a year past, having been treated for worms, incontinence 
of urine, and pain in the stomach, the disease of the spine never 
having been suspected until a few weeks ago, when a physician 
was called to see him, who immediately recognized Pott's disease 
and sent him to me. 

The patient's parents were too poor to buy a Taylor's brace 
which I intended to put upon him, and the disease, in fact, had so 
far progressed as to require of the child the recumbent position 
for some time before even a Taylor's brace could be used to ad- 
vantage. As I before said, they were too poor to buy any mechani- 
cal apparatus, and as perfect quiet of the spinal column was requi- 
site, I had the child held up by the arms (the weight of the body 
acting as an extending force), pinned his little flannel shirt around 
his thighs, stretching it over his body smoothly, and, commencing 
at the pelvis, applied rollers saturated with plaster of Paris over 
his entire trunk, the same as you would to the thigh in dressing a 
fracture. 

The only fear I had in making this application was of con- 
stricting the chest so as to interfere with respiration ; but, as the 



PLASTEE-OF-PAEIS JACKET. 373 

child cried lustily during the whole operation, this fear was re- 
moved. He appeared able to press the diaphragm down so as to 
give plenty of room for respiration, notwithstanding that the dress- 
ing was entirely around the thorax. 

He was held in this position, suspended by the arms, for twenty 
or thirty minutes, until the plaster became set. Then the cuirass, 
as it might properly be called, was divided in the median line from 
the sternum to the pubis, when, of course, his respiration became 
perfectly easy. The lower portion around the pelvis was then 
secured by a roller, making it a firm support, and the upper por- 
tion of the dressing was tied at various points by an elastic band- 
age, allowing it to expand for respiration ; and, as his parents say, 
he has been perfectly comfortable ever since, has grown quite 
fleshy, and is now able to walk about without resting his hands 
upon his knees. 

This child was returned to me only an hour ago, and I present 
him to you to show the practical effect of the application of this 
plaster-of -Paris dressing, as it is the first time I have used it in 
this way. I have frequently employed the plaster extending two- 
thirds around the body, which I have termed " turtle-shelling," 
but never before carried it clear round, encircling the entire body. 
As you all know, the streets are nearly impassable from the small 
icebergs interspersed here and there, and therefore we have been 
jolted in the most severe manner while coming in a carriage from 
my office to the college, and yet the child has never complained 
at all, although the parents say that it was impossible to move him 
before without using the greatest care. 

We will remove the cuirass, for the first time since I applied 
it six weeks ago. The angle of the curvature is very much less 
sharp than when the instrument was applied, and the child's gen- 
eral health has improved immensely. [The professor then showed 
the plaster-cast to the class, the mother holding the child in her 
lap in the mean time. It was then readjusted, when the mother 
remarked that the child could now sit up, but when the dressing 
was off it could not sit up at all — which, as the professor men- 
tioned, was the best proof of the efficacy of the treatment,] 

The advantages of this plan are these : Its simplicity, its econ- 
omy, the material for its construction being attainable anywhere, 
its ease of application, the readiness with which it can be readjust- 
ed as the growth of the child requires, and the accuracy of the 



374 DISEASES AND DEFORMITIES OF THE SPINE. 

fit, giving the child more comfort than any instrument which 
could be made, unless over a plaster model, which would be very 
expensive, and even those that are made over a model to fit in the 
most accurate manner, when they come to have the trimmings 
and padding applied to them, have lost their accuracy of fit and, 
therefore, make uneven points of pressure. The objection to the 
use of plaster is that it is not very clean ; but this can be obviated 
by using starch, flour and eggs, silicate of sodium, or anything 
else that will assume the shape of the body and retain its form. 

It is not altogether improbable that this simple dressing may 
yet supersede all the complicated and expensive apparatus we 
have heretofore employed in the treatment of this disease. 

When the deformity has been produced and become anchy- 
losed the position is fixed, and any attempt to completely correct 
it, or to break up the partial consolidation that may be present, is 
unjustifiable. All that can be done under such circumstances is, to 
hold the body as well as possible in the position which it is made 
to assume, and permit the bones to get well with the deformity 
remaining. 

A most excellent and serviceable adjuvant to all these sup- 
ports is the wheel-crutch, invented and manufactured by Mr. 
Darrach, of Orange, K J. (Fig. 221). The idea involved in the 
construction of the crutch is to keep the patient in an upright 
position, with support under the arms, and avoid the intermitting 
strain and swinging action attending the use of the ordinary 
crutch. By sustaining the body of the patient in a pendent posi- 
tion without fatigue, the diseased parts are relieved of pressure, 
while the patient can have all the benefits of exercise without 
injury. The erect posture, however, is not desirable except so 
far as is absolutely necessary to permit' exercise and obtain fresh 
air ; but, when the erect posture is assumed, the trunk should be 
supported by artificial means, applied in such a manner as to 
remove all pressure from the bodies of the diseased vertebrae, 
until complete consolidation has taken place. This crutch, there- 
fore, answers a very good purpose ; but I believe there is noth- 
ing that can take the place of 

Plaster of Paris as a Dressing in Pott's Disease.— -Since 
this lecture was delivered, the prediction then made has been 
fully realized (January, 1876) by the application of the plan sug- 
gested, in more than sixty cases, with the happiest results. I 






PLASTER-OF-PARIS JACKET. 



375 



therefore feel quite justified in proposing it as a proper plan of 
treatment. At first I was afraid that the thoracic compression 
would interfere with respiration, and therefore divided the 
cuirass in the median line as soon as the plaster was set ; I 




Fig. 221. 



then secured the lower or pelvic portion with a firm, non-elastic 
roller, and the upper or thoracic portion with elastic bands to 
allow more free lateral expansion of the chest. Practical expe- 
rience, however, has demonstrated that this is not necessary — 
but, on the contrary, is injurious, particularly if the disease in- 
volves the sides of the bodies of the dorsal vertebrae — and that the 
complete circling of the thorax in the immovable plaster bandage 
in these cases gives the greatest relief, as by this means the ribs 
are held absolutely motionless, and the respiration is compelled 
to be diaphragmatic and abdominal. When the thorax is thus 
firmly secured, the anus and perinseum will rise and fall synchro- 
nously with the diaphragm, and the respiration be carried on 



376 DISEASES AND DEFOKMITIES OF THE SPINE. 

without difficulty, as long as these parts are free from pressure. 
Pressure upward against these parts with the hand produces 
a feeling of suffocation. It is therefore necessary, when the 
thorax is thus secured, that the patient should sit upon a chair 
with a hole in the seat, like a close-stool, or use an inflated India- 
rubber ring, like the ordinary life-supporter. 

As it is difficult for an assistant to hold these patients sus- 
pended long enough to apply the dressing and have it set proper- 
ly, Mr. Reynders has contrived a very convenient apparatus for 
that purpose, which I have found most useful. {See Fig. 222.) 
It consists of a curved iron rod, with a hook in its centre and at 
each end. From the end-hooks loops pass down under each 
axilla, and also to the chin and occiput, to support the head. To 
the centre hook is attached a pulley, and, the opposite pulley being 
secured to the ceiling or some other safe attachment of sufficient 
height, the patient is easily elevated by the bands under the axilla, 
chin, and occiput, until the heels cannot touch the floor. 




Fig. 222. 



In some cases of an adult, or even very heavy children, the 
pressure on the axillary plexus of nerves produces numbness of 
the fingers. In such cases I have found great relief from apply- 



CASE. 377 

ing an additional roller-bandage from the axilla across the chest, 
front and rear, to the opposite hook, as seen in Fig. 224. 

This plaster-dressing can be changed or removed as often as 
necessary to accommodate the increased growth or development 
of the patient. 

The ease of application in any section of the country without 
the trouble and expense of resorting to any specialist or instru- 
ment-maker ; the perfect comfort given to the patient by protect- 
ing the diseased parts from pressure, without galling or chafing 
any other part, as is almost always done even by the best-fitting 
instrument ; and the absolute immobility which can be obtained 
by the plaster-bandage, will, I feel confident, give this plan the 
preference over any yet adopted for the treatment of Pott's dis- 
ease, or caries of the spine. 

To illustrate the advantage of this plan of treatment, as well 
as to point out some modifications in its application in certain 
peculiar cases, I will narrate a few of the cases in which it has 
been applied : 

Case. Pott's Disease. — John J., aged five years, of perfectly 
healthy parents ; in January, 1873, Pott's disease appeared, in 
the lumbar region, for which no cause could be assigned. A 
wheel-crutch was used until April in the same year. In May, 
1874, a raw-hide jacket was fitted to the child, which gave great 
relief. The child was again seen in 1874, when he looked well. 
He continued to run about until June 4, 1875, during which 

7 7 o 

time he had outgrown the jacket, which was removed and a 
plaster-of-Paris dressing applied. The child was held out as 
straight as possible by two assistants pulling, one from the shoul- 
ders and the other from the ankles, a flannel shirt having been 
adjusted to his body ; then a bandage, saturated with plaster of 
Paris, was carried around the pelvis and up to the axilla. 

The plaster dried readily, and the child was sent home feel- 
ing perfectly comfortable. 1 I was sent for that evening in great 
haste, the mother saying he could not " lay or sit," and found 
him suffering from too great compression of the thorax. I there- 
fore made an incision of about three inches from the top, through 
the plaster-of-Paris dressing, which gave instantaneous and per- 

1 Experience has taught me that suspension of the body in the sling makes more 
comfortable adjustment of the plaster-jacket than when applied with extension in the 
horizontal posture. 



378 DISEASES AND DEFOEMITIES OF THE SPINE. 

feet relief. This dressing was worn until July 26th, when it was 
found that a fold in the shirt had produced uneasiness. It was 
then taken off, and a slight abrasion over the crest of the left 
ilium discovered. The child came to the office on the 30th, when 
the abrasion was found healed, and was told to return the next 
day, when the dressing would be reapplied. 

July Z\st. — Another dressing was applied, the child being 
placed in the sling, the body being the extending power. The 
plaster of Paris was applied as before. After the plaster had 
dried, the child walked about the office, feeling very comfortable. 

On the following Tuesday he went on an excursion, and, up 
to this day (August 12th), has suffered no pain. 

September 22, 1875. — Was present at the clinic; his jacket, 
that had been applied July 31st, was removed. The boy could 
bear concussion, even when the instrument was off, without pain, 
and appeared to be perfectly well, the dorsal and lumbar vertebrae 
being anchylosed and without deformity. Another plaster-jacket, 
however, was applied (before the class), to guard against any pos- 
sible accident. 

November 1st. — Jacket sawed open and removed. Boy appar- 
ently perfectly well, firm consolidation having taken place. He 
is allowed to wear his jacket, as a matter of convenience — to 
satisfy himself — although not necessary. 

January 1, 1876. — Perfectly well, and needs no support. 

Case. Pottfs Disease, from Injury. — Mr. ~W. was brought 
to me, July 26th, by Dr. Arrowsmith, of Keyport, New Jer- 
sey. The patient gave the following previous history : 

"Was out riding and thrown from his wagon, striking on his 
left side and back ; was unable to move for a short time; about 
two hours afterward regained perfect control of himself. One 
week later, as he did not feel very well, sent for a physician, who 
said he thought he had inflammation of the bowels, caused by his 
injury. Was treated for some time, and got no relief. Latterly 
he was examined by other physicians, who differed in their diag- 
nosis, and, not being satisfied with their opinion, he went to 
St. Luke's Hospital, where he remained and had a " Taylor's 
brace " applied for Pott's disease ; was brought to my office, when 
I examined him and confirmed this diagnosis. 

Present Condition. — Patient very much emaciated. Posi- 
tion as seen in Fi£. 223. The sensation of constriction around 



CASE, 



3T9 



the abdomen is the most marked feature of his suffering. He 
cannot walk, or lie on his back with any comfort ; can only lie on 
the abdomen ; even then requires to be pulled out to free him 




Fig. 223. 



from pain. Suspending the body, the arms being thrown over 
the shoulders of another person, gives relief. 

I applied the plaster-dressing, as before described, in presence 
of Drs. R. Taylor, A. A. Smith, and others, and, when it was 
dry, he said he was more comfortable than he had been for twelve 
months. The next day he called, and said : " The principle is 
correct, but it has been applied imperfectly ; my back has a 
vacant space on each side of the spinous processes the entire 
length, and it requires filling up." 

He was so very thin that the spinous processes projected to 
such a degree that the bandage bridged over a vacant space on 
each side, and he felt the want of this support. Not having time 
to apply it on this day, I made an appointment for the following 
Friday. 

"When he came on Friday, he stated that he had made another 
discovery r that he had no room to put his dinner, and wished me 
to fold a pad over the abdomen, and bandage over it, so that, 



380 DISEASES AND DEFOKMITIES OF THE SPINE. 

when the plaster had become set, it could be pulled out, and the 
rest of the dressing not be disturbed. 

I redressed him, assisted by Drs. R. Taylor, Yale, Eose, and 




Fig. 224. 



my two sons. On account of the pain from pressure in the axilla, 
I applied additional support by carrying a roller-bandage through 
the axillae across the chest, front and rear, and securing it to the 



CASE. 381 

hooks at each end of the curved iron rod, as seen in Fig. 224. I 
then placed several strips of bandage, saturated with plaster, on 
each side of the spine. 

I then dressed it as usual, after padding the abdomen as sug- 
gested. 

Patient called at my office five or six days afterward, and 
stated that he had never been so comfortable since he was hurt. 

He has now gone on a fishing-excursion, and the last heard 
from him was that he was perfectly comfortable. 

Case. Pott's Disease.— Michael N., aged three years, of 
healthy parents. Was always healthy till December, 1874, when 
his mother noticed a stiffness of the right side. He was treated 
for hip-disease, in an institution in this city, without relief. 
March, 1875, the mother noticed a swelling on the right side of 
the spine, which gradually increased to the size of a hen's-egg. 
Was examined in my clinic, and aspirated. I found pus, and a 
free incision was made ; also, on examination, found Pott's dis- 
ease in lumbar vertebrae. He was then dressed with plaster of 
Paris, and a fenestra left for the escape of pus. 

The child wore the dressing six weeks, when he began to com- 
plain of pain. The plaster was then removed, and it was found 
that an abscess had formed below and to the right of the old one. 
A free incision was made, connecting these two abscesses, which 
afforded great relief. The wound was filled with Peruvian bal- 
sam and oak am, a piece of oiled silk put over it, and his shirt 
drawn firmly over all and made smooth, when the plaster-jacket 
was applied as before, while the child was suspended. A pin, 
passed through a folded bit of pasteboard or card, was placed over 
the wound, so that each turn of the bandage, passing over the 
pin, made a certain guide to the point over which we wished to 
cut a fenestra. When the plaster had become nearly set, a fenes- 
tra, three inches wide and about five inches in length, was cut 
around the pin, until we came down to the oiled-silk. This was 
then starred in lines from its centre, and the edges of it turned 
over the plaster-bandage, and the space carefully stuffed with 
oakum, to prevent burrowing of pus, made a nice drain for the 
discharges of the abscess (as seen in Fig. 225). 

The dark and dotted lines (Fig. 226) show the relative posi- 
tion of the spinal column before and after suspension. 

The wound was kept clean with oakum and Peruvian-balsam 



382 



DISEASES AND DEFOKMITIES OF THE SPINE. 



dressings, and a tight roller passed over it every day. The child 
was able to walk about without any assistance on the day after 
the last dressing was applied, since which time he has been per- 
fectly comfortable and free from pain. 




\ 



Fig. 225. 



Fig. 226. 



October 20th. — The child was brought to the office, the mother 
saying that he was getting so fat that his jacket was too 
tight. The wound had stopped discharging for more than a 
fortnight, and the child had the appearance of almost robust 
health. 

Case. Pott's Disease ; Injury. — Minnie O'B., aged three 
years, of healthy parents. About November, 1874, she fell down- 
stairs. Shortly after she began to complain of a pain in her stom- 
ach. The mother found that the abdomen was very hard and 
swollen. The child has not been able to stand erect since ; the 
mother states that she was always comfortable when lifted by the 
arms. Three months ago a small lump appeared in the lumbar 
vertebrae, about the size of a hickory-nut. July 28, 1875, she was 
brought to me, and on examination I pronounced it Pott's disease. 
Child was suspended in the apparatus and I applied the plaster- 
of -Paris dressing on the 4th day of August, in the presence of 



CASE. 



383 



several physicians, since which time the child has been perfectly 
comfortable and free from pain. 

September 1st. — Child complained of pain ; dressing removed 
and found a small abrasion from a fold in the shirt. 

5th. — Re-dressed in plaster-jacket ; perfectly comfortable. 

October 7th. — Child has been in the country since last report. 
Returned to-day, very much improved in general health, feeling 
well, running around without cane or crutch, and the mother say- 
ing that it is impossible to keep her quiet.- 

Having put up some sixty cases in the plaster-jacket, almost 
all of which had previously worn instruments for a greater or less 
period of time, and every one of the patients giving the prefer- 
ence to the plaster-jacket to any other mechanical support which 
had been applied to them, I feel quite confident in recommend- 
ing it as a plan of treatment, and will merely quote one more case 
as an illustration of the improvement that can be made in the 




OCCiPUT 



Fig. 227. 




position, by suspending the patients before the permanent dress- 
ing is applied. 

Case. — C. E. G., five and a half years old, sent to me from 
West Virginia, by Dr. Campbell, September 1, 18T5, suffering 



384 DISEASES AND DEFORMITIES OF THE SPINE. 

from Pott's disease in the seventh, eighth, and ninth dorsal verte- 
brae. 

She was unable to stand without support, either upon her 
crutches, or hanging on to chairs or tables, or sustaining herself 
by her hands upon her bent thighs. 

The disease began to develop itself after an injury, having 
fallen upon her back early in the spring of 1874. In the month 
of June, 1874, she was taken to the National Surgical Institute, 
Indianapolis, where she had an iron brace applied to her, and which 
she had worn from that time until the present, and, although a 
remarkably well-htting instrument, it had not prevented the curve 
from taking place, as seen in Fig. 227. 

By having a piece of lead rolled out in the form of tape, I was 
enabled to accurately mould it to the curve in her back (as seen 
in dark line, Fig. 228), and after the child was suspended under 
the axilla and from the chin and occiput, in the usual way, for a 
few moments this leaden tape-measure was again applied the en- 
tire length of the spine, and the change in position is seen by the 
dotted line, Fig. 228, thus proving with a positive mathematical 
certainty the change that had taken place in the curve of the 
spine. 

The plaster-jacket was then applied over a nicely-fitting shirt, 
and the following day she ran without any crutches or cane, very 
much to the father's surprise, and returned to her home in West 
Virginia. 

Six weeks afterward I received a letter from her father, stating 
that she had improved both in health and spirits, and that her 
relatives and friends were perfectly astonished at the great change 
in her form and carriage. She simply suffered after eating, and 
he feared that the jacket was growing too tight, and suggested 
the propriety of its removal, and the application of cotton-batting 
over the stomach, which was to be removed after the jacket had 
set, an almost exactly similar suggestion to that made to me by Mr. 
"W., upon whom I first applied a pad under the jacket. 

November 3d, I received another letter, reading as follows : 

" Charleston, West Virginia, November 1, 1875. 

" My deae Doctoe : The case you put on my little girl became so tight 
and uncomfortable that I got our family physician, and we tried our hands at 
a removal. I am glad to report our operation a perfect success. 

"Our patient is quite lively to-day, and a marked improvement in her 



CASE. 385 

breathing is discernible, as we put the cotton - batting over her stomach 
before putting her up, afterward extracting it, thus giving her plenty of room 
for breathing and eating. 

"I send a picture of her present condition, and you can see how much 
straighter she is than when you first saw her. {See Fig. 229.) 

" "We feel confident from the improvement that has been made, and the 
comfort that she has enjoyed by the use of the jacket, that her recovery will 
be perfect and complete. 

" Gratefully yours, John W. G-." 

If there are any cases in which it would be justifiable for the 
application of the actual cautery, this can easily be done by mak- 



Fig. 229. 



ing a fenestra over the place where the cautery has been applied, 
the same as in the case above reported where an abscess existed. 

It is possible that a flat India-rubber bag placed over the abdo- 
men for the purpose of being inflated during the time that the 
plaster is being applied, and which can have the gas let out of it 
after the plaster has set, will accommodate the digestive process, 
similar to the cotton-batting that these two patients have instinc- 
tively suggested for themselves. Doubtless many other improve- 
ments may be made in the application of this principle before it 
is brought to perfection. 
25 



386 DEFORMITIES OF THE SPINE. 

LECTURE XXVI. 

DEFORMITIES OF THE SPINE. — ROTARY-LATERAL CURVATURE. 

The Term Rotary-Lateral Curvature explained. — Pathology of the Deformity. — Class 
of Persons in whom it occurs, and how it is developed. — Additional Causes. — 
Special Cause when the Deformity is developed in the Dorsal Region. — Symptoms. 
— Treatment. 

Gentlemen : To-day we continue the study of deformities of 
the spine. The next in order is what is commonly known as 
lateral curvature, but, for reasons which will be given a little 
farther on, I prefer to call it the rotary-lateral curvature. 

There has been vastly more written upon this deformity, and 
more instruments devised for its relief, than for almost any other 
deformity that may occur in the human body. 

Lateral curvature of the spine is always accompanied by a 
rotation or twisting of the bodies of the vertebrae upon them- 
selves. In children, the spinal column is nearly straight, and 
remains in that condition until they begin to assume the erect 
posture. When, however, they begin to assume this posture, the 
psoas magnus and iliacus internus muscles begin to act upon the 
lumbar spine and pelvis, and draw the pelvis forward into the 
angle it normally occupies relative to the long axis of the body 
in the adult, at the same time giving to the sacrum its peculiar 
curve. The muscles of the back, in addition, develop a back- 
ward compensatory curve in the dorsal region, in order that the 
centre of gravity in the body may be properly maintained. 

The spinal column is held in its normal position by the con- 
tractions of muscles situated upon either side of it, which exactly 
balance each other. If, for any reason, one set of muscles over- 
comes the set upon the opposite side, the spine yields, and a curve 
is produced with its concavity toward the side upon which the 
stronger set of muscles is situated. 

Kotary-lateral curvature depends entirely upon abnormal mus- 
cular contraction, and occurs independently of softening and dis- 
integration of the vertebrae and intervertebral cartilages; for 
these are rarely, if ever, affected in this disease. The rotary 
curvature is developed first, and sometimes takes place to such an 



CAUSES OF LATERAL CURVATURE. 387 

extent that the angles of the ribs may be mistaken for the pro- 
jecting spinous processes in Pott's disease, as seen in this speci- 
men. (See Fig. 233, page 395.) 

In all these severe cases, however, the bodies of the verte- 
brae remain of normal thickness, and the deformity is dne to ab- 
normal muscnlar contraction, accompanied by a rotation of the 
bodies of the vertebrae one upon another. 

There is simply compression of the posterior and expansion 
of the anterior portion of the intervertebral disks, but no disease 
of these disks or of the vertebras. 

The true pathology, therefore, of rotary-lateral curvature of 
the spine is abnormal muscular contraction. This contraction 
produces at least two curves, which occur most commonly in the 
lumbar and dorsal regions. The secondary curve, whichever it 
may be, is called compensatory. 

Sometimes the lumbar curve is developed first, and then the 
dorsal curve becomes compensatory ; and vice versa. It is im- 
portant, however, to ascertain which curve made its appearance 
first, for it is in the pathological condition which has produced 
the first curve that the surgeon is chiefly interested, for the 
secondary curve is merely compensatory, and is produced in con- 
sequence of the presence of the first. 

It is a noticeable fact that this deformity never occurs in those 
persons who are compelled to maintain an erect position. For 
instance, those who are accustomed to carry weights upon their 
heads, such as baskets of clothes or pails of water, do not get 
lateral curvature of the spine, simply because they are obliged to 
maintain the body in a perfectly erect posture, and that is done 
by causing the muscles of the trunk to contract with equal force 
upon both sides. 

Half of these deformities are the result of want of energy, 
want of life enough to sit up straight ; consequently are most 
commonly seen among that careless, lifeless class of persons who 
are in the habit of sitting the greater share of the time with 
their backs twisted and bent in a half -curved position. Indul- 
gence in such careless habits of sitting not infrequently develops 
a curve in the spinal column at some point, which is sufficient to 
establish the deformity ; and then in a very short time a second 
curve will be developed, which is compensatory. Again, fracture 
of the femur or tibia, when followed by considerable shortening, 



388 DEFORMITIES OF THE SPINE. 

causing the body to lean toward the side upon which the fracture 
took place, may be sufficient to establish lateral curvature of the 
spine. 

Shortening of one of the lower extremities may be the result 
of paralysis followed by arrest of development. The conse- 
quence is, an unequal support to the sides of the pelvis ; hence 
one side drops down, and with this depression comes a lateral 
curve in the spine. These are the more prominent causes that 
give rise to this deformity when it exists in the lower portion of 
the spinal column. 

When the first curve in the spine, is developed in the dorsal 
region, it depends upon an entirely different cause, and is due to 
the action of the inspiratory muscles. 

As you all know, the great serrati muscles are the most im- 
portant external inspiratory muscles in the body, and when the 
shoulders are fixed these act in such a manner as to elevate the 
ribs and increase the capacity of the chest. 

This can be easily understood, when we refer to the relations 
of these muscles a little more in detail. The serratus magnus 
arises, by eight or nine fleshy digitations, from a corresponding num- 
ber of ribs, and passes in different directions, backward, and upward 
and backward, until it reaches the posterior portion of the scapula, 
when it is inserted into the entire extent of its base. Now, in 
order that the scapula shall be a firm point of support, from which 
the serratus magnus may act, it is fastened to the spinal column 
by means of the rhomboidei muscles; so that, so far as acting upon 
the ribs is concerned, for the purpose of increasing the capacity 
of the chest, and also upon the bodies of the vertebrae, these two 
sets of muscles become practically a single set, with the movable 
scapula between them. 

With such a muscular arrangement what do we have ? We 
have a means of applying a force which, every time an inspiration 
is made, acts upon the vertebrae through the ribs, which play the 
part of levers of greater or less length. When a full inspiration 
is taken, this action is much more marked. 

JSTow, you will observe that the ribs, bending at their angles, 
rest against the transverse processes of the dorsal vertebrae. The 
head of the rib, an inch or inch and a half from this angle, rests 
against the bodies of two of the vertebrae, slightly sloping upward. 
We thus have the ribs, at their angles, resting against the trans- 



CAUSES OF LATERAL CURVATURE. 389 

verse processes of the vertebrae, like a fulcrum, the short arm 
running to the head of the rib against the bodies of the vertebra?, 
and the long arm being the body of the rib, and the power which 
moves this lever is the serratus magnus muscle, which is inserted 
into this long arm. Now, when the trapezius and rhomboidei 
contract and draw the scapula backward toward the spine, they 
thus make tense the serratus magnus muscle on that side, and 
give it full power to act upon the ribs, and by this leverage ro- 
tate the spine upon itself. 

This is the starting-point of the so-called lateral curvature, 
but, as it begins in a rotary movement of the bodies of the verte- 
bra?, I prefer to call it rotary-lateral curvature. 

In the lumbar curve the bodies of the vertebra? are usually 
twisted to the left, while in the dorsal curve they are ordinarily 
twisted to the right. Why this is so I am not prepared to say. 
This order, however, may be reversed. 

When a curve becomes established by the action of one serratus 
muscle, it is liable to become gradually increased on account of 
the progressive relaxation of the opposing serratus muscle. Some- 
times this curvature becomes so great that one lung is almost 
completely compressed, and the angles of the ribs upon that side 
may become almost obliterated, while those upon the opposite 
side become correspondingly acute. (See Fig. 233.) 

This deformity occurs much more frequently in girls than in 
boys. In its very commencement it may be due to apparently 
trifling affairs, those which favor the undue contraction of certain 
muscles ; it may be due to the slight relaxation given to the muscles 
of one side of the trunk, by assuming an improper posture while 
sitting; standing habitually in a half -leaning, careless position, 
upon one leg, or frequently throwing one arm behind the body, 
thereby making the serratus magnus upon that side more tense 
than the other. 

Any of these apparently trifling causes, approximating one 
scapula nearer to the spinous processes than the opposite one, 
render the serratus magnus on that side tense, and thus place it 
in a favorable position for undue action on the ribs of that side, 
and thus commence a distortion. As already stated, when the 
curve is once established, it is very liable to increase rather than 
diminish. 

Rotary-lateral curvature of the spine may be corrected before 



390 DEFORMITIES OF THE SPINE. 

the bones, ligaments, and ribs become fixed in their abnormal 
position ; bnt when that has occurred, the deformity will be per- 
manent. It is important, therefore, to be able to recognize the 
deformity in its earliest development. 

Symptoms. — One of the earliest symptoms is an undue promi- 
nence of one of the scapulae. If, therefore, this be present, 
always examine the spine; but even at this stage of the de- 
formity if a curve is found, if you will remove the weight of the 
head and shoulders from the spinal column, by placing your 
hands in the axillae and lifting the patient up, the curve will en- 
tirely disappear ; or, if the patient is laid face downward upon a 
table, the spine will be found to be perfectly straight, or can be 
made so by a trifling amount of extension. But, if the patient 
stands without support under the arms, you can, by carefully not- 
ing the situation of the spinous processes (which can be done con- 
veniently by rubbing the finger over them, thus producing a red- 
dish line, or by dotting them with ink), detect a curvature, very 
trifling it may be, in the dorsal region. 

Now, if the deformity is permitted to go uncorrected, it will 
gradually increase as the spine yields to the muscular contractions 
assisted by the weight of the head and shoulders, until finally, as 
the body sags over, it is fully developed. The deformity does not 
advance far in the dorsal before a compensating curve is de- 
veloped in the lumbar region. 

Treatment. — Almost an innumerable variety of instruments 
have been devised for the treatment of this deformity. 

The use of all fixed apparatus in the earlier stages, as in the 
treatment of all deformities where we wish to restore lost muscu- 
lar power, is positively injurious. The principle which should 
guide you is, to place upon the stretch those muscles which have 
leen inactive and relaxed, and approximate the origin and inser- 
tion of the muscles you wish to remain quiescent. 

The great serrati muscles are the ones chiefly affected by this 
principle. 

What we wish to accomplish is, first, to place the serratus 
magnus, upon the same side as the dorsal curve, in such a position 
that its fibres will be at rest. This can be done by carrying the 
arm of that side across the chest, in such a manner that the hand 
meets the upper portion of the lapel of the coat. 

Second, we wish to place the fibres of the opposite serratus 



TREATMENT. 391 

magnus in as tense a condition as possible. This can be done by 
carrying the arm, npon this side behind the body, as in the act of 
placing the hand in the back coat-pocket. When the arm is 
placed in this position, the scapula is drawn backward, and the 
serratus muscle is in the most favorable position for contracting 
with all its power, thereby rotating the bodies of the vertebrae 
back to their normal position. In this manner the patient is 
unrolled, as it were, and this must be done before any benefit will 
be obtained by treatment. 

You will therefore instruct these patients to habitually cany 
the arms in the positions mentioned, and at the same time prac- 
tise taking full inspirations. The result is that, by fastening the 
scapulae in this manner, the lung upon the side of the relaxed 
serratus is changed very little in size when the full inspiration is 
made ; but, the fibres of the opposite serratus magnus now placed 
upon the utmost stretch, the full inspiration has a tendency to 
lift up the angles of the ribs upon this side, and curve them back 
to their normal position, and thus gradually unfold the de- 
formity. 

There are several aids in carrying out this principle, which 
are of great service. One is to cause the patient to sit upon an 
inclined plane, the lower side of which corresponds to the de- 
pressed shoulder, which is placed at such an angle as will neces- 
sitate a constant muscular effort to keep from falling off. Such 
an inclined plane can be attached to any chair, and in such a 
manner as the ingenuity of the surgeon may suggest. 

In some cases, in the early stages, the benefit derived simply 
from sitting upon such a stool a certain number of hours, every 
day, is sufficient to overcome the deformity. The patient should 
never sit upon the inclined plane long enough to produce muscu- 
lar fatigue, and should immediately resume the horizontal post- 
ure when not thus sitting. 

But, when the inclined plane is used in connection with the 
position of the arms already described, still greater effect can be 
produced by an elastic force so applied as to assist the mus- 
cles in unfolding the deformity. This can be accomplished 
by fastening elastic bands, which have handles attached to their 
free extremities, to hooks in the wall on either side of the patient. 
The bands should be of such a length that, when the patient sits 
with the arms in the position before described, she can just grasp 



392 



DEFORMITIES OF THE SPINE. 



the handles. Now, while she is sitting in this position, direct her 
to inflate the lungs as much as possible, and at the same time 
make traction upon the elastic bands, and then let the expiration 
be gradual. The elastic bands should be stiff enough to give 
quite firm support to the arms. 

These simple adjuvants to the general treatment are worth 
more than all the appliances I have ever seen devised for the 
correction of this deformity in its earlier stages, i. e., before the 
bones have become changed in form. 

Another elastic apparatus that can be used with benefit is 
one devised in accordance with an idea I first obtained from Mr. 
Barwell, of London. It is more of a reminder to the patients 
what thej are to do than anything else, but at the same time 
furnishes considerable aid in the efforts made to straighten them- 
selves by means of muscular contraction. (See Fig. 230.) 

It consists of a piece of sole-leather four or five inches wide, 




Fig. 230. 



and six or eight inches long, with its upper end hollowed out like 
a crutch ; this is placed under the axilla of the depressed shoul- 
der ; a band going over the opposite shoulder is buckled to the 



APPARATUS FOR LATERAL CURVATURE. 393 

lower end of this leather crutch in front and behind. This band 
on either side has a few inches of elastic inserted, so that it has 
a constant tendency to lift the depressed shoulder, which is, in 
fact, suspended from the opposite one. Two other bands, one in 
front and one behind, descend from the top of the crutch to the 
opposite hip, and are there secured to a piece of leather, which 
is retained in place by a perineal band going around the thigh. 
From the centre of the crutch, two elastic bands, one in front 
and one behind, go around the body to another piece of leather 
placed over the projecting portions of the ribs upon the opposite 
side of the body. This leather pad is retained in position by 
straps descending from the first-mentioned strap over the shoul- 
der, and also has elastic bands extending to a*nother piece of 
leather over the opposite hip, which is secured like the first hip- 
piece by a perineal band going around the thigh. 

All these bands are made partially of elastic webbing, and by 
their constant contraction have a tendency to twist the body 
straight, or rather to untwist it from its distorted position ; but 
their practical object is to act as a reminder to the patient of the 
necessity of his making voluntary action of his own muscles for 
the purpose of keeping himself straight. 

In the very early stages of this deformity the distortion can 
be rectified by instructing the patient to use his muscles, so as to 
cause their development in exactly the opposite direction to that 
which has produced the deformity. 

We never see this deformity in that class of persons who use 
no restrictions to the fall development of the muscles of their 
trunk by tight lacing or bad dressing, and who are in the habit 
of carrying baskets, pails of water, or other articles, evenly bal- 
anced on their heads. The servant-girl, walking with a basket of 
clean and well-ironed linen poised upon her head, is compelled to 
carry her head erect, or lose her balance, when down come the 
clothes in the mud, and with the loss of her balance she also loses 
her place, if she receives no further punishment. Take a hint, 
gentlemen, from this practical fact, and teach your young lady 
patients to walk about the room with a book upon their heads 
several minutes at different times during the day. This simple 
act alone will cause an equipoise of muscular power which Will 
prevent the occurrence of this deformity, and even correct slight 
distortions when first commenced. Swinging from the arms, or 



394 



DEFORMITIES OF THE SPINE. 



from the rings as in the gymnasium, is also very valuable exer- 
cise to accomplish this object. 

A spiral corset may be worn with advantage. It is made 
by having spiral springs, a few inches longer than the corset, 
quilted into pockets, and forcibly pressed into these pockets and 
retained there, so that the corset is constantly making efforts to 
extend itself. (See Fig. 231.) As the patient is generally smaller 
at the waist than at the upper or lower extremity of the trunk, 
this corset is very much like a double cone in shape, and, the 
patient's trunk having been extended, it is placed upon him or 
her by first fastening the central point at the waist, and then the 




Fig, 231. 



slope of the corset above and below. On account of the constant 
action of the spiral springs, it will keep the patient extended, and 
prevent deformity. 

In the majority of cases of the deformity in their earlier 
stages, before the bones and ligaments have become changed in 
form, the treatment above described, together with vigorous out- 
door exercise, to improve the tone of the general system, will 
generally be found all that is required to correct it. 



CASE OF LATERAL CUKVATURE. 



395 



There are cases, however, like the one now before you (Fig. 
232), in which the deformity has lasted so long, and the bones 
themselves have become so changed in form, that the deformity 
can never be perfectly rectified. 

This man's deformity commenced as a lumbar curve on the 
left side, caused by his thigh on that side being one inch shorter 
than the other, and the dorsal curve has been produced as a com- 
pensating curve. This deformity has been greatly aggravated and 
made permanent by his avocation, which was carrying large bas- 
kets, by placing his left hand on his hip, making a resting-place 
on his left shoulder and arm, and holding the basket in place by 
throwing his right hand over his head and holding on to the top 
of the basket. You see that he has an immense muscular devel- 





Fig. 232. 



Fig. 233. 



opment ; the ribs of his left side are drawn down below the crest 
of the ilium, and that his body is rotated to the right, almost 
through one-quarter of a circle, an almost counterpart of the speci- 
men here seen, in which the distortion was so great, that by many 
it was mistaken for Pott's disease, or posterior angular curvature, 
instead of lateral {see Fig. 233). In this specimen you observe a 



396 



DEFOEMITIES OF THE SPINE. 



line drawn at right angles with the anterior portion of the lumbar 
vertebrae, instead of being parallel to a similar line drawn from 




Fig. 234. 



the middle of the dorsal, is at right angles to it, although parallel 
to a line drawn from the cervical. 



SECTION OF LATISSIMUS DORSI. 397 

This shows that the vertebral column has been twice twisted 
upon itself ; you see how admirably this specimen illustrates the 
deformity of this patient now before you. 

When I place this man within a sling passing under his axillae, 
and another band under the chin and occiput, and elevate his 
body by drawing upon the pulley {see Fig. 231), you immediately 
see this broad band of the latissimus dorsi muscle brought promi- 
nently into view, and it is an impossibility to bring him straight 
until this muscle is either cut. or ruptured. While he is thus 
stretched out, I make pressure upon this muscle with my finger, 
and he instantly has a spasmodic contraction of nearly all the 
muscles of his body, thus proving that this muscle is contractured, 
and that no power, no matter how long continued, can stretch it 
to its normal condition, unless the fibres are severed, and this 
must be done either by force or with the knife. On the con- 
trary, I have proved to you over and over again, in the many 
cases of contractured tendons and muscles which have have been 
here, that, when this structural shortening has taken place, tohich 
is made evident by the reflex spasm which is produced in it 
by pressure upon its fibres when under extreme tension, con- 
tinued stretching tends only to irritate that muscle and cause it to 
undergo stronger and stronger contractions, and that any attempt 
to stretch a muscle thus changed in structure excites additional 
irritation, rather than produces any elongation of its fibres. 

If this rule, which I have laid down for some years, and fol- 
lowed in practice with the greatest success with almost all the 
other muscles of the body, be a correct rule, it should be applica- 
ble to this case. Believing it to be correct doctrine, I shall, there- 
fore, proceed to divide the muscle. 

You all see that this strong band, some three inches in height, 
which, with all my force, I can stretch no further, gives me a 
reflex spasm every time I pinch it. This fact seems to me to 
make section of it perfectly justifiable. 

I take this long, strong tenotome (made especially for the 
purpose), and pass the blade under the anterior edge of the latis- 
simus dorsi nearly opposite the angle of the scapula, and, passing 
it under the muscle, I now turn its edge toward the surface and 
cut with a short, sawing motion, while, with my thumb, I press 
upou this firm, tightly-drawn band. You hear the snapping of 
the fibres as they are being divided, and, now that they are all 



398 



DEFORMITIES OF THE SPINE. 



cut, see how instantaneously the spinal column is rendered almost 
straight ; I instantly turn the knife upon its side, withdraw it, 
and close the wound with my thumb, having pressed out a few 
drops of blood. I now dress the wound with adhesive plaster 
and a firmly-adjusted roller. 

The patient states that the operation has given him but trifling 
pain, and that he feels very comfortable. 

You all must observe the wonderful change in his form. The 
spinal column has become almost straight, the only distortion ex- 
isting being at the angles of the ribs upon the right side, and this 
has existed so long that it may possibly be permanent. 

We can now take the man down from the sling, and, as he lies 




Fig. 235. 



upon the table, he expresses himself as being free from pain. He 
will be put to bed, with a broad band passed around the upper 
portion of the trunk, secured by an India-rubber strap to a fixture 
upon one side of the bed, and a similar band around the pelvis, 
secured in a similar way to the opposite side of the bed. Between 



ANCHYLOSIS. 399 

these two elastic forces the body will be retained in the straight 
position, and we will show you the result at our next clinic. 

.By reference to Fig. 235, engraved from a photograph taken 
twelve days after the operation, can be seen the present condition 
of the patient while sitting unsupported on the side of his cot. 



LECTURE XXYII. 



ANCHYLOSIS. 



Derivation and Use of the Word. — True and False Anchylosis.— Position of Limb when 
Anchylosis becomes a Necessity — Mode of determining which Form of Anchylo- 
sis is present. — Br isement force. — Mode of dressing the Limb after the Operation. 
— Cases. 

Gentlemen : To-day we begin the study of anchylosis. 

Anchylosis is a word derived from the Greek (ay/cvXos, crooked 
or hooked), and has been used to designate immobility of a joint, 
because most of the joints when stiffened are deformed in this 
crooked manner. 

Although the true pathology is stiffness, immobility, or consoli- 
dation, no matter whether in a straight or crooked position, yet 
the term anchylosis, or crookedness, has been so long used by the 
profession to designate the pathological condition of which we 
are now speaking, that I shall continue to employ it. 

Anchylosis is either true, osseous, or complete ; or false, fibrous, 
or incomplete. True or complete anchylosis signifies the fixed 
and absolutely motionless state of a joint. False, fibrous, or in- 
complete anchylosis denotes a limited motion in the joint, no mat- 
ter how slight that motion may be. 

Anchylosis is more common in the ginglimoid articulations 
than in others, but may occur in every description of joint. In 
general, only one joint is anchylosed in the same individual ; but 
I have seen one case, in a gentleman under thirty years of age, 
from Providence, Rhode Island, in which both hips, one knee, and 
both ankles, were apparently completely anchylosed, as the result of 
rheumatic inflammation. I have seen one other case, in a young 



400 ANCHYLOSIS. 

lad of fifteen, from Kentucky, who had disease of his right hip- 
joint,, and, for the purpose of procuring rest of that joint, was put 
by his attending surgeon into a fixed apparatus, embracing the 
trunk, pelvis, and both lower extremities, and so retained for 
several months. At the end of this time, the diseased hip was 
cured by anchylosis, and the knee and ankle of the diseased limb, 
as well as the hip, knee, and ankle of the opposite one, were com- 
pletely anchylosed, and still remain in the same condition. 

In this case there had been no inflammatory action in any of 
the joints, except the right hip, and he had never complained of 
or suffered pain in any of them. This case is of great importance, 
showing as it does that anchylosis can take place even in a young 
person, in a perfectly healthy joint, by long-continued rest. 

In old age, anchylosis, in certain parts of the skeleton, is a 
natural change ; and in this period of life it is common to find 
the heads of the ribs anchylosed to the bodies of the vertebrae, or 
the tubercles to the transverse processes, the vertebrae to one an- 
other, the ensiform cartilage to the sternum, etc. 

Anchylosis is not a disease of itself, but may be the result of 
any disease, affection, or injury, which interferes with the normal 
functions and motions of a joint. 

Anchylosis may be the most favorable termination that can 
occur in many diseases and accidents of the joints. In such cases 
it is of the most vital importance that the surgeon should select 
the most favorable position for the future usefulness of the limb 
thus involved. As, for instance, the elbow is more useful when 
anchylosed at a right angle than if made straight, whereas the 
knee would be entirely useless if anchylosed in the same manner ; 
its future usefulness and security being better obtained by hav- 
ing it anchylosed perfectly straight, or as nearly so as may be. 

It has been customary among surgeons, when anchylosis was 
the best result that could be obtained in any given case, to secure 
it with the leg flexed upon the thigh at an angle of 30° to 45°. 
From this I dissent, and recommend that you should secure anchy- 
losis at the knee-joint with the limb in a straight position. 

My reason for preferring this position is this : it gives a more 
secure position and one that is not liable to give the patient trouble 
at some future date. 

If left to anchylose at an angle, the anchylosis is very inse- 
cure, and sometimes, as the man steps down an unexpected distance 



POSITION FOE ANCHYLOSIS OF KNEE. 401 

or slips, bringing his weight suddenly to bear upon the limb bent 
at this angle, it may yield sufficiently to give hiro very serious 
trouble. 

It was only yesterday, as I was riding down Broadway, that 
I saw a gentleman about fifty years of age who, in getting out of 
an omnibus, just opposite the Metropolitan Hotel, slipped, and 
fractured his anchylosed knee that had been in a condition, as he 
supposed, of firm bony anchylosis for eleven years, and had never 
given him any trouble whatever. 

He had been able to walk and stand upon it with perfect ease 
and apparent security, but, by this accidental slip, an additional 
weight was thrown upon the joint anchylosed at a slight angle, 
and the attachments were fractured, and the man rendered help- 
less. I have known of quite a number of similar instances. 

If, on the contrary, the bones are placed in the straight posi- 
tion as nearly as may be, the large, articulating surfaces of the 
tibia and condyles of the femur give such an immense expanse 
for attachments to be formed as to render that portion of the 
limb even more secure against fracture than any other part of it. 

When the accident happened to the man in Broadway, it be- 
came necessary to carry him some distance before he reached his 
home, where he could receive surgical attention, thereby endanger- 
ing an attack of inflammation in a tissue which had formerly been 
the seat of disease. In other words, he had had his anchylosis 
brokeu up, but was in a situation that prevented that immediate 
treatment which I regard as so important ; whereas, when the 
fracture is made intentionally, treatment is immediately begun, by 
securing rest, position, pressure, extension, control of circulation, 
all of which are essential to prevent inflammation after forcible 
rupture. 

The man away from home, who accidentally breaks his anchy- 
losed joint, cannot have these advantages, and hence the danger 
of leaving the knee to anchylose in such a position as will render 
the patient liable to such accidents. 

The straight position has been objected to, upon the ground 
that it places the patient in a very awkward and inconvenient 
attitude when sitting. That may be true, but I regard a secure 
position which will, perhaps, prevent any accident, as being pref- 
erable to insecurity, although it be accompanied with a greater 
degree of comeliness. 
26 



402 ANCHYLOSIS. 

It is owing to the neglect of observing this principle of plac- 
ing a limb in its most favorable position for future usefulness, 
while consolidation is taking place, that subsequent surgical inter- 
ference is necessary. 

In chronic or long-continued inflammation of any joint, reflex 
irritation, producing muscular contractions, invariably takes place. 

This contraction not only aggravates the disease by causing 
undue pressure on the parts inflamed, but also distorts the limb 
in accordance with the action of the most powerful muscles in- 
volved, and the distortion can only be prevented by the proper 
application of an extending and counter-extending force during 
the treatment of the disease. When this principle has been neg- 
lected, the patients frequently recover with such seriously distorted 
and useless limbs as to render surgical interference necessary. 

In such cases it is of the utmost importance to ascertain whether 
the anchylosis be complete or incomplete, as the plan of treatment 
in each particular case depends entirely upon the accuracy of this 
diagnosis. If fibrous, or incomplete, it can be broken up by 
manual or mechanical force, aided by subcutaneous tenotomy, 
myotomy, and the section of such fasciae, fibrous bands, and other 
adhesions, as have prevented its mobility ; whereas, if the anchy- 
losis be true, or bony, the deformity can only be relieved by section 
of the bone itself with the saw or other instrument. In many 
cases of simply fibrous or incomplete anchylosis, the adhesions are 
so firm and so short as to allow of no perceptible motion, even 
under a very careful inspection. In such cases, if any motion 
whatever has been made, although so slight as not to be observed 
at the time, the parts which have been subjected to the violence 
necessary for the examination will on the following day give 
evidence, by pain, tenderness, and inflammation, that some motion 
must have been given to the parts involved. In one case of 
anchylosis of both hips, with very great distortion, by complete 
flexion and adduction, in a young girl of nineteen, from long-con- 
tinued suppuration of both hip-joints, the anchylosis was so com- 
plete that, in consultation with all the surgeons at Bellevue Hos- 
pital, we all decided that it was a case of osseous fusion, and could 
only be relieved by section of the bone. 

On the following day, when I went to perform the operation, 
there was so much tenderness about the parts, that I was satisfied 
some motion had been given to the articulation, although so slight 



FORCIBLE EXTENSION. 403 

that none of us had been able to detect it at the time of the ex- 
amination. I therefore determined to break np the adhesions, 
instead of sawing out a portion of the bone. The adductors 
tensor vaginee feinoris, and fascia lata, of both sides were subcu- 
taneously divided, the wounds carefully closed and covered by 
long strips of adhesive plaster and compresses. A figure-of-8 
roller was then carefully applied around each hip, after which the 
adhesions were forcibly but very freely broken up, and the limbs 
brought as nearly as possible to their natural position, and retained 
there, by extension and abduction, by weights and pulleys, which 
were secured to the limbs, in the usual way, by adhesive plaster 
and roller. The patient was kept perfectly quiet, the parts kept 
cool with ice-bags, and at the proper time passive motion was 
made. The result in this case was perfectly satisfactory, the 
patient recovering, with good motion of both joints. She has 
married since, and was delivered, by the late Dr. George T. Elliot, 
of a living child, who is now a robust boy, of live years of age. 
Previous to the operation, this woman could only walk upon her 
hands and feet, the limbs being closely flexed and adducted, and 
the anchylosis so complete, as before stated, that all who examined 
her thought it to be osseous. She is now in perfect health, and 
performs all her household duties without the aid of a servant. 

Having made our diagnosis that the anchylosis is fibrous, and 
not osseous, how shall it be broken up ? In former times gradual 
extension, with steaming and friction, was considered all that 
was necessary, but the length of time demanded and the great 
pain induced by this method of treatment, frequently prevented 
the patient and surgeon from carrying it to the completion of 
securing perfect motion. The slow and gradual stretching of 
tissues, long contracted, produces reflex contractions in many 
instances to such a degree as. to compel the treatment to be aban- 
doned, and patients prefer to remain with their limbs in the dis- 
torted condition rather than undergo the constant pain of con- 
tinued extension. 

In all such cases, it is infinitely better to proceed to the im- 
mediate restoration of the joint to its normal position, with entire 
freedom and mobility, by manual force under the influence of an 
anaesthetic combined with tenotomy or myotomy of subcutaneous 
section of the fascia, if necessary, than to resort to the slow pro- 
cess of gradual extension. 



404 ANCHYLOSIS. 

In all such cases, however, it is of the utmost importance that 
manual force should not be resorted to for breaking up fibrous 
anchylosis, until all traces of joint-disease have subsided. Then 
we may resort to hrisement force, and not until then. 

How are we to decide whether tenotomy, myotomy, or the 
section of fascia is requisite ? Put the parts upon extreme ten- 
sion, and, while thus stretched, if point pressure by the linger 
or thumb, made on the fascia or tendon thus stretched, produces 
reflex contractions, then that fascia, tendon, or tissue, must be sub- 
cutaneously divided or else forcibly ruptured before the limb can 
be restored to its normal position. If the tissues thus contracted 
can be reached with the knife without the danger of involving 
large blood-vessels or nerves, section by the knife is better than 
forcible rupture. If it is necessary to make this subcutaneous 
section, it is better to do it three or four days previous to the 
breaking up of the joint, so that the external wound made by the 
tenotome may have healed before the latter operation is per- 
formed. This tenotomy may be performed under the influence 
of an anaesthetic, or not, as the surgeon chooses ; but wiien the hrise- 
ment proper is performed an anaesthetic is absolutely essential. 
In fact, it is due to anaesthesia that hrisement force has gained its 
reputation, and to it it chiefly owes its success. 

The patient being thoroughly anaesthetized, the limb is seized 
by the hands of assistants, holding it with firmness, between the 
joint involved and the trunk, while the surgeon takes the farther 
extremity of the limb and forcibly flexes it upon itself, which is 
frequently attended with sharp snaps and cracks that are some- 
times quite audible and that are very "distinctly felt by the sur- 
geon's hand while making the rupture. Having flexed it suffi- 
ciently to begin to allow of moderate movements, he then reverses 
the movement, and forcibly extends it ; and in this way, by forcible 
flexion and extension, continues until he has gained perfect and 
free motion of the joint involved in all its normal movements. 
If the knee is the joint involved, care must be first taken to fract- 
ure off the patella from its attachments to the femur, which is 
sometimes the most difficult part of the operation to be per- 
formed. In many instances the surgeon can aid himself by cover- 
ing the handle of the key with buckskin, and by its use give him- 
self a firmer leverage against the edge of the patella than he can 
get with his naked thumb. Having thus obtained perfect exten- 



BRISEMENT FORCE. 405 

sion, and flexion, in fact, the complete movements of whatever 
joint involved, these movements are repeated with great freedom 
and with great frequency until all the adhesions are thoroughly 
and completely broken up. 

One of the commonest causes of failure in the treatment of 
fibrous anchylosis by brisement force is, that the surgeon, succeed- 
ing in getting a moderate motion, and becoming alarmed at the 
audible fractures that occur, contents himself with that slight mo- 
tion for the present operation, intending to complete the cure by 
subsequent operations, and thus, by making frequent attempts to 
increase these slight movements, sets up a new inflammation in 
the parts involved, preventing any further interference, and fre- 
quently resulting in a more firm consolidation of the joint than 
before ; whereas, by breaking up the adhesions thoroughly and 
completely at the time of operation, and then by proper dressings 
of the parts and the prevention of inflammation, he may confi- 
dently expect that he will have a much more satisfactory result. 

How are these dressings to be applied ? and how is this inflam- 
mation to be prevented \ This I look upon as the most impor- 
tant part in the treatment of an anchylosed joint. For many years 
past I have always adopted the following plan : If, for instance, it 
be the knee which I have broken up for angular fibrous anchylo- 
sis, I first strap the toes with strips of adhesive plaster if it be a 
small subject, or, if an adult with long toes, pad the toes with cot- 
ton and bind with bandage, carrying the roller over the foot 
strongly and firmly, padding the malleoli and tendo-Achillis with 
cotton ; the roller is carried snugly over them ; two strips of ad- 
hesive plaster having been placed on either side of the leg for ex- 
tension, the roller is passed over them, leaving the lower extremi- 
ties of the adhesive plaster exposed for the future attachment of 
weight and pulley, and is carried up as far as the top of the tibia. 
The popliteal space is then padded and firmly strapped with 
strips of adhesive plaster, each one shingling over the other until 
the entire knee is covered. The roller is then continued over the 
knee smoothly and very firmly until you come to the junction of 
the middle and lower third of the femur, when a piece of sponge 
an inch or two in length, or about the size of your thumb, first 
being wet in cold water, is placed over the track of the femoral 
artery, and the roller carried on over this sponge for the purpose 
of making partial compression of this artery, so as to diminish its 



406 ANCHYLOSIS. 

calibre and .thus prevent the full supply of blood to the parts be- 
low. Great caution is necessary, in the application of this pressure 
upon the artery, not to obstruct the circulation so as to produce 
gangrene ; we must here use pressure without abusing it. 

This piece of sponge should be kept soft and elastic by wet- 
ting it occasionally with cold water through the bandages. If 
permitted to get dry, it will be like a hard foreign body, and the 
pressure made upon it will be much .more liable to cause slough- 
ing. 

The limb is then secured in an absolutely immovable position, 
either by a wooden splint well padded placed behind the leg, 
gutta-percha, sole-leather, plaster of Paris, iron bars on either side 
of it, or in any way that the surgeon may deem best for the pur- 
pose of preventing the slightest possible movement. The patient 
is then placed in bed, the lower extremity of which is raised ten 
or twelve inches higher than the head of the bed, so that the body 
may act as a counter-extending force, and the weight and pulley 
applied over the foot of the bed to the strips of adhesive plaster 
at the ankle-joint before described. Ice-bags are then placed 
around the knee, and such constitutional treatment in the way of 
narcotics, cathartics, etc., as may be required is judiciously used. 
At the end of six or seven days the dressings are removed, the 
sponge taken from over the femoral artery, the adhesive straps cut 
from over the knee, and the parts carefully examined, and a very 
slight movement given to the joint for the purpose of prevent- 
ing solidification, when the dressings are reapplied with the 
sponge left off from over the femoral artery. At this dressing 
the surgeon will often be surprised to find ecchymosis to some 
extent, both above and below the joint, from extravasated blood 
caused by the rupture of vessels at the time of the operation ; but, 
by following the plan that I have here laid down, I have never 
seen a case that went on to suppuration since I have adopted this 
method of treatment, now numbering nearly one hundred cases. 
The extension is still continued and the elevated position of the 
limb is preserved for some days, until all danger of inflamma- 
tion is past, the surgeon exercising his judgment whether the 
application of ice is still to be kept up or not. At the end of a 
few days the dressings are again removed, and more free motion 
is given to the part. It may be necessary at the time of making 
this movement, and the three or four subsequent movements, to 



PASSIVE MOTIOX. 407 

administer an anaesthetic; these movements should be made 
quite free when an anaesthetic is used, the surgeon being careful 
not to carry them to the point of exciting new inflammation. After 
some days the passive movements can be made daily, accompanied 
with friction, and shampooing should be very liberally done. 
These movements may be increased in frequency as the case ad- 
vances, until Anally an instrument can be so adjusted to the limb 
that the patient can cause the movements many times in the day 
without the attendance of his physician. {See Fig. 236.) So soon 




Fig. 236. 



as the parts can be pressed together by bearing the weight of the 
body upon the foot without tenderness, the extension can be 
omitted, and the movements daily increased. 

These are the general principles which should guide you in 
the management of all cases of fibrous anchylosis, whether occur- 
ring at the hip, knee, elbow, or other joints. 

When the hip-joint is operated upon by brisement force, I 
usually secure the patient at once in the wire cuirass. The wire 
cuirass is also an exceedingly convenient instrument to be used 
when the knee-joint has been broken up, especially in children. 

The circulation of the hip can be controlled by placing a bag 
of shot over the external iliac artery. 

When the elbow and wrist joints are operated upon, the sponge 
is placed over the brachial artery for partial compression and 
control of the circulation, the same as already described when 



408 ANCHYLOSIS. 

speaking of the femoral artery in reference to the prevention of in- 
flammation of the knee. After the roller-bandage and arterial com- 
pression have, been properly applied, the joints are to be secured 
against the possibility of the slightest motion- for a few days. After 
all danger of producing inflammation has passed, then the same 
general principles laid down to you. in the treatment of anchylosis 
of the knee-joint are to govern you, such as friction, shampooing, 
passive motion, etc., being careful never to carry your treatment 
to the extent of reexciting inflammation. 

By the plan of treatment here given I have never had a single 
case of constitutional fever or suppuration following brisement 
force of any of the joints; and, as before stated, I have per- 
formed the operation, including the different joints, more than 
one hundred times. I therefore feel that I cannot urge upon you 
too strongly the necessity of carrying out all the details of the 
after-treatment I have laid down, for I have seen a number of 
cases in which brisement force has been performed by competent 
surgeons, but they neglected to apply extension, and the result 
was that reflex muscular contraction followed, which prevented a 
successful termination of the operation ; or, they allowed a little 
time to elapse after the operation before the dressings were ap- 
plied, and a reaction came on which prevented their application, 
and disastrous inflammation followed. I regard every detail of 
the plan of treatment as essential, and cannot urge you too strongly 
to observe them all. 

Case. Anchylosis of Knee ; Brisement Force ; Result per- 
fect ; from Bellevue Hospital Records. — " R. D. S., June 29, 
1869, aged twenty-two ; Kentucky. On the 11th of December 
last, patient accidentally shot himself with a Colt's revolver, the 
ball entering the right thigh, on its anterior aspect, midway be- 
tween the groin and the knee. 

" It lodged in the tissues, on the outer side of the patella. The 
next day the ball was removed. Patient says that his knee then 
began to inflame, getting swollen, red, and painful. 

"There was much discharge through the opening made by 
removing the ball, and patient was confined to his bed for two 
months. 

"During this time his knee became anchylosed, almost in a 
straight line. 

" On admission to hospital, the right thigh and leg were smaller 



CASE. 409 

than left, the following measurements being taken : Eight thigh, 
fifteen and three-eighths inches in circumference ; left thigh, 
seventeen and one-eighth inches in circumference ; right leg and 
calf, ten and a half inches in circumference ; left leg and calf, 
twelve and a quarter inches in circumference. 

" There is barely any motion of the joint. The patella is 
slightly movable. 

" Patient's general condition good. He gives no history of 
hereditary disease ; the limb gives him no pain. 

" June 30th. — To-day the patient was etherized, and Dr. Sayre 
broke up the adhesions with little trouble, so that the leg could 
be completely extended, and flexed at an acute angle upon the 
thigh. The toes were strapped, the foot and leg bandaged, a 
large sponge strapped into the popliteal space, and another placed 
over the femoral artery, so as to compress it moderately. A long 
splint of leather was then adapted to the back of the thigh and 
leg, and bandaged firmly. 7 p. m. — Patient doing well ; has some 
pain ; ordered liq. morphias sulph. (U. S. P.), 3 iij. 

"July 1st. — Slept well last night, and has no pain in knee. 
7 p. m. — Foot rebandaged. 

" 6th. — Since last note patient has been doing well. To-day 
Dr. Sayre took off the splint and bandage, and made passive mo- 
tion, which was very painful. Patient was then anaesthetized, 
free passive motion made, and dressing reapplied. 

" 7th. — Joint was moved again. 

" 9th. — Splint removed to-day. Patient out of bed. 

" 14:th. — Joint moved to-day under chloroform. From this time 
the motions were made more frequently, and an instrument ad- 
justed, so that the patient could flex and extend the limb at his 
pleasure. He was advised to do this frequently every day. The 
result was, that he recovered with perfect motion in less than three 
months." * 

Case. Necrosis of Lower End of Femur, complicated with 
Fibrous Anchylosis of 'Knee-Joint ; Brisement Force ; Recovery 
with Motion. — G-. W. O., of Bloomingdale, aged twenty-four 
years ; fell, when he was ten years old, from a height of ten 
feet, striking upon his right limb, followed by a periostitis of the 
lower end of the femur, ending in necrosis of femur and anchy- 
losis of the knee-joint. When he was fifteen years of age (after 

1 I saw Mr. S. in January last, and his limb was as perfect as the other. 



410 ANCHYLOSIS. 

a lapse of five years), one of the sinuses on the outer portion of 
the thigh was dilated, and a piece of bone two and a half inches 
in length, and about two-thirds of the circumference of the femur, 
was removed. A sinus existed at the same time on the inner 
aspect of the thigh connecting with the external one. A perfo- 
rated India-rubber tube was passed through its track and worn 
for some time, until all dead bone had come away. His leg at 
that time was flexed at an acute angle with the knee. 

The wounds of the thigh healed after a few months, when, 
under the influence of chloroform, by hrisement force, his limb 
was made perfectly straight, dressed in my usual way with a 
partial compress over the femoral artery, binding the knee, retain- 
ing splint, extension by weight and pulley, ice-bags to the knee- 
joint. No constitutional or other irritation followed the operation. 
At the end of seven days the dressings were removed. Consider- 
able eccbymosis appeared around the neighborhood of the knee 
from the rupture of blood-vessels at the time of the operation, 
but no excessive heat or other evidence of inflammatory action. 
The limb was very slightly moved and again redressed as before, 
with the exception of the sponge compress upon the femoral 
artery. In two days it was again redressed and more free move- 
ments given it. 

From this time on, the dressings and motions were made 
daily for about a fortnight, when the passive movements were 
advised to be made several times within the twenty-four hours. 
These movements were constantly increased, until, at the end 
of three months, the cure was perfect and complete, with the 
entire mobility of the joint, complete extension and perfect flex- 
ion, as is now seen in the case before you. (See Figs. 237 and 
238, showing flexion and extension; the depressions on either 
side of the limb are the cicatrices whence the bone was removed.) 

Case. Fibrous Anchylosis of Knee / Brisement Force ; Re- 
covery with Motion. — Joseph S., aged seven years, was brought 
to me October 30, 1873. The following scanty history of the 
case was all that could be elicited : 

When two years old he had rheumatism. The joint chiefly 
affected was the left knee. The father says, " His physician 
called it ' bony anchylosis ' and ' white swelling? r It was treated 
with iodine externally ; no extension. The limb was always 
crooked, but he could walk upon it until the summer of 1872, 



CASE. 



411 



since which time the present distortion has existed. There is 
fibrous anchylosis of the knee. The tibia is luxated backward. 





Fig. 237. 

There is very slight motion of the joint ; the patella is probably 
movable. {See Fig. 239, from photograph.) 

December 6, 1873. — At the college clinic I divided the ham- 
string tendons of the left limb subcutaneonsly without loss of 
blood. The patella was then forcibly separated from the end 
of the femur, and the limb drawn down to the position of com- 
plete extension, and retained by a weight-and-pulley dressing. 
The limb was dressed in my usual manner, viz. : the instep and 
ankle were well padded with cotton, the roller neatly applied 
over this and up the leg. The popliteal space is protected by a 
large soft sponge. The inequalities of the knee being carefully 
padded, strips of strong adhesive plaster are snugly drawn over 
the sponge and pad, and the whole covered by carrying the roller 
up over the knee and lower part of the thigh. A small piece of 
sponge is then placed over the course of the femoral artery, 
above the junction of the middle and upper third of the thigh, 
and the roller carried farther up and completed by a spica. The 



412 



ANCHYLOSIS. 



boy was taken directly to lodgings, put to bed, and a dose of 
morphia given him. 

11th. — Dressing removed and reapplied. Most excellent con- 
dition in every way. 

20th. — Came to clinic with extension-brace, which was applied 
yesterday. Motion good ; passive motion ordered. Returned to 
his home in Yorkville. 

January 12, 1874. — Has for a week past complained of pain, 
particularly for the past three days. Compression in axis of 
limb gives pain. Extension gives relief. Knee-extension instru- 
ment ordered. 

April 1st. — Boy walked into my office without crutches. In- 
strument readjusted. Suffers none from knee, but has symptoms 
of " chills and fever." Lives near the " Yanderbilt improve- 
ment," 2 Ninetieth Street. Ordered quinine and iron. 




Fig. 239. 




Fig. 240. 



June 1st— General condition good ; still tender over lower 
insertions of lateral ligaments. Instrument readjusted. 

1 The " Vanderbilt improvement " has reference to the sinking of the Fourth 
Avenue Railroad. 



CASE. 413 

23<#. — Boy doing well. Instrument not removed, but band- 
age reapplied. 

August 1st. — Instrument removed; walks well, with good 
motion, about one-third normal freedom. (See Fig. 240.) 

Case. Fibrous Anchylosis ; Knee sub-luxated; Brisement / 
Recovery with Motion ; Death from Typhoid Fever Three 
Months after the Operation. — "William M., aged nine years, from 
Auburn, New York, came to me November 5, 1868, and gave 
the following history : About June, 1864, the father noticed that 
the lad began to drag his left foot. He complained of no pain, 
and appeared to have nearly perfect power over the limb. Five 
or six months later the knee began to swell, and appeared to be 
"filed with water" This condition continued for about two 
years. Gradually the swelling disappeared. He was treated at 
intervals during the continuance of the trouble by various physi- 
cians. About two years since, the child was ordered to go upon 
crutches, no attention being paid to the contraction. The limb 
was then nearly straight, but since that time the contraction 
has gradually increased. For the last eighteen months the limb 
has been nearly as " tough and sound " as the healthy one, saving 
the contraction. 

The position of the limb is as follows : The leg is sub-luxated 
backward and outward slightly. There is slight motion at this 
new joint. The patella is apparently adherent by bone. 

6th. — Drs. Hamilton and Krackowizer saw the patient with 
me. While examining the patella, Dr. Hamilton thought he de- 
tected motion. This was rendered certain by the following ma- 
noeuvre : Dr. Hamilton placed his finger upon the groove between 
the patella and external condyle, so that the sharp edges of the 
two bones could be at the same time felt. I then made firm 
pressure upon the inner edge of the patella, and the two edges of 
bone before mentioned were felt to approximate, the patella 
slightly overriding the condyle. The opinion of the consultation 
was, that an attempt should be made -to restore the normal posi- 
tion of the limb ; that, under anaesthesia, as much as possible 
should be done, and the limb retained in the position gained, by 
a splint, or by extension, according as might be best in practice. 

9th. — The boy was chloroformed, and the limb forcibly 
straightened as far as possible. While the limb was firmly held 
in proper position, a weight-and-pulley extension was applied. 



414 ANCHYLOSIS. 

The vessels were protected by a sponge in the popliteal space. 
The supply of blood to the joint was diminished by the pressure 
of a small sponge placed over the femoral artery and confined by 
the bandages. 

27th. — Made a second operation. At this sitting the limb 
was brought nearly straight, the hamstrings were probably 
broken. The limb was fixed by a posterior leather splint. No 
reaction of importance followed. 

December \§th. — The limb is nearly in perfect line. Passive 
movements have been employed for two or three weeks. Put on 
an instrument for angular motion of the knee. The boy left for 
home ; treatment to be continued under direction of his family 
physician. 

February, i869. — The father writes : " The knee had im- 
proved very much, when the boy was seized with typhoid fever 
and died." 

Case. Fibrous Anchylosis of Left Knee. — Catharine B. was 
admitted to Bellevue Hospital June 3, 1868, when she gave the 
following history (copied from hospital register) : " She was 
confined April 1, 1868, and remained in bed but two days after. 
On the 1 3th of April she first noticed pain in the left leg and 
knee. Very soon the parts became much swollen, red, and very 
tender ; at the same time she had chills, fever, and sweat. She 
was compelled to keep the bed for four weeks. Since her admis- 
sion to the hospital, the knee has been blistered, compressed with 
sponges, and extended. All these plans seemed to be of some 
benefit. Passive motion, showering with alternate hot and cold 
water, have been employed with little effect upon the anchylosis. 
For several months the joint has been anchylosed, the angle being 
about thus / — 135°." There is at present but little pain in 
the knee, though she says " it is worse in damp weather." 

At clinic, January 6, 1869, I made the following comment on 
the case, previous to operating : The hectic sweats, etc., lead to 
the belief that this was a case of pyarthrosis, but the liquid has 
since been nearly all absorbed, and it was probably all synovia. 
The anchylosis is at too great an angle, and I shall therefore try 
by brisement to place it in a better position. The patella seems to 
be movable. There is some danger of reexcitation of inflamma- 
tion by the brisement, since hitherto all attempts at establishing 
motion have been attended with considerable reaction. There is 



CASE. 415 

one point, below and outside of the patella, which is still tender. 
"I do not hope in this case to get motion.," I applied the pre- 
paratory dressings as usual. The patella was started off by bend- 
ing the limb backward, and then straightening it. Free motion 
was given to the joint. The knee had become slightly inverted ; 
this was straightened by pressure. The usual dressings of sponges 
and plaster and roller, with a posterior splint, were applied. Di- 
rected absolute rest for ten or twelve days. 

" 13th. — No reaction took place. Everything proceeding per- 
fectly well. Patient has had no pain after the first thirty-six 
hours succeeding the operation. 

" 20th.— Extension no longer giving relief, was removed as 
unnecessary. 

." February loth. — Has continued to do well. 

" May 1st. — Has continued to improve ; is walking with the 
aid of a stick. 

" 14:th. — Having left the hospital on a pass, and overstaid her 
time, she was discharged to-day." 

Case. Anchylosis — Hip; Recovery with Good Motion. — 

Miss , of Hudson, N. Y., was brought to me by Dr. P., 

of Claverack, N. Y., November 27, 1867, giving the following 
history : 

"When three years old, she caught her foot in a hole and fell. 
She was able to walk home, but complained of severe pain, and 
was confined to the bed for two years from that time. During 
this time the right lower limb became strongly flexed on the pel- 
vis, and aclductecl across the upper portion of the opposite thigh. 
Previous to the injury she had been perfectly healthy. 

Since she was five years old she has been able to go round on 
crutches, and for the last six or seven years has been able to flex 
the thigh upon the pelvis and extend it slightly, but cannot 
abduct it at all. 

General health perfect, and tolerably robust. Eight limb 
five inches shorter than the other ; that is, the foot cannot be 
brought within live inches of the floor. (when the sound limb is 
straight), and it is very strongly adducted. 

A line drawn from the right tuberosity of the ischium around 
the hip, to the anterior superior spinous process of the ilium of 
the same side, passed nearly three inches below the top of the tro- 
chanter major, which could be distinctly felt on flexion and exten- 



41 % ANCHYLOSIS. 

sion of the thigh upon the pelvis, showing that a new joint had 
been made upon the dorsum of the ilium, but, on account of the 
adduction of the limb, she could bear no weight upon it without 
falling on the right side. 

I put her under chloroform, and, by moderate force with my 
hands, very slowly and gradually abducted the limb, Dr. Phil- 
lips holding the pelvis quiet, when, suddenly, the tendon of the 
adductor longus snapped off with quite a loud noise. After a 
few minutes I was able to abduct the thigh to nearly a right 
angle with the body, the pelvis being held still and the other 
limb being straight, showing that the motion was in the new hip- 
joint and not in the lumbar region. The recovery from chloro- 
form was slow, but at the end of two hours she could rise and 
walk with the limb straight under her. She could voluntarily 
abduct the limb six inches from the central line of the body. It 
was now only two inches shorter than its fellow, and could nearly 
support the weight of the body. 

The patient returned to Hudson on the same day in a sleep- 
ing-car, without experiencing any trouble, having been carefully 
bandaged on a well-padded board, and, on reaching home, was 
put to bed and fomented. 

December 1st. — I saw her in Hudson ; found her perfectly 
comfortable, and she had suffered no pain since the operation. 
There was a slight discoloration upon the inside of the thigh. 
She is able to flex, extend, and abduct the limb, and to bear her 
entire weight upon it without pain, if she has gentle support to 
prevent her falling, the muscles not being strong enough to sus- 
tain or steady her body. 

I directed that the limb should be rubbed, shampooed, and 
that faradism should be applied to it. 

l%th. — Dr. P. reports, " Case still improving." 

September, 1868. — Miss called upon me. The limbs 

are parallel. The limb formerly anchylosed can now T be moved 
voluntarily in every direction, and over quite a large arc. The 
knee of the diseased side is considerably above that of the sound 
side. The right limb, measuring from the top of the trochanter 
major to the external malleolus, is one inch shorter than the left. 
This shortening is increased by the position of the head of the 
femur, so that, measuring from the anterior superior spinous pro- 
cess to the internal malleolus, the shortening is two and a half 



CASE. 417 

inches. The discrepancy is made np by a thick cork-sole, and she 
walks well with the assistance of a cane. 

Case. Fibrous Anchylosis of Sip ; Tenotomy / Brisement ; 
Recovery, with Motion. — G-. W. S., aged fourteen years, con- 
sulted me for the first time, September 17, 1872, and gave the 
history of his case as follows : 

Nearly ten years before, he was attacked with hip-clisease on 
the left side, as the result of a fall. The trouble continued for five 
years, during which time the disease progressed to the third stage, 
abscesses formed, were opened and discharged, small pieces of 
bone coming away from time to time. No large pieces have 
ever been discharged. 

About five years from the beginning of his trouble, while 
running, he caught and twisted his foot in a rope. For several 
weeks afterward he was unable to move without the greatest 
suffering. He subsequently improved, and became quite sound 
and strong. 

Health good. Wears, in walking, four and a half inches lift 
upon the left shoe. He is not easily fatigued in walking, and 
does not complain of pain. When his trunk and the sound 
limb are in normal position, the affected limb is flexed and 
addu-cted, the left foot falling upon the outside of the right knee. 
(See Fig. 2il, from drawing by Dr. Yale.) It is brought down to 




Fig. 241. 

a position permitting walking by strong tilting of the pelvis. It 
is possible that the second accident, above mentioned, may have 
increased the motions of the joint. 

September 28th. — Under chloroform, I divided subcutaneously 
the tendons of the adductors (pectineus, adductor-longus, gracilis) 
and the tensor vaginae f emoris ; dressed the usual way, and placed 
in the wire-breeches. 

October 12th. — No inconvenience has been experienced by the 
patient. He was removed to-day from the wire-breeches. 

19th. — Was allowed to ride out. 
27 



418 



ANCHYLOSIS. 



December 6th. — Has had a two-inch lower-heeled shoe con- 
structed ; called to-day to show it. Walks very well with it ; the 




Fig. 242. 



Fig. 243. 



Fig. 244. 



limbs are parallel when walking, as seen in Fig. 242, and he is 
able to flex the thigh upon the pelvis to a right angle (as seen in 
Fig. 243), and also abduct it (as seen in Fig. 244), from photo- 
graphs. 

Case. Anchylosis of Hip- Joint from Rheumatic Inflamma- 
tion of Seven Years' 1 Standing successfully treated by Tenotomy 
and Brisement Force. — H. H. R., aged twenty-eight, was brought 
to me for treatment in June, 1861. 

In April, 1854, when twenty-one years of age, he caught cold 
by sleeping on damp ground in California while engaged in min- 
ing. He was confined to bed about a year with acute rheumatism, 
which involved nearly all the joints in the body, but at last settled 
in his hip, which became contracted and finally anchylosed (as seen 
in Figs. 245 and 246, from photographs). Fig. 245 shows his mode 
of walking, with a very high heel on his boot, and even with this 
assistance he has to bend his spine and other knee to such an extent 
as to compel him to use a crutch in order to sustain himself. Fig. 
246 shows his position when attempting to stand erect. It will 



CASE. 



419 



be seen by the curve in the lumbar region that the femur is at 
right angles to the pelvis, and his foot is elevated just thirteen 
inches from the ground by actual measurement. A number of 
cicatrices are on the outside of the thigh, and the tissues beneath 






Fig. 245. 



Fig. 246. 



Fig. 247. 



them are attached to the bone. The limb is very firmly anchy- 
losed in position, as seen in the figures, and has been so for the 
past seven years. 

The man is remarkably muscular and robust, but complains 
bitterly of the strain upon him in walking in his bent posture, and 
is anxious to have relief, even if his limb has to be amputated. If 
his joint cannot be broken up, he thinks cutting off his limb high 
up would remove the strain upon his back and enable him to 
walk much better on one leg than he can now do on two, and is 
therefore very anxious to have me perform amputation in case 
I cannot give motion. 

June 10, 1861, 1 divided the tensor vaginae femoris and fascia, 
rectus femoris, and adductor longus, and with considerable diffi- 
culty at last broke up the adhesions around the joint and got the 
limb in a very good position. 

The adhesions must have been mostly by osteophytes, and ex- 



420 ANCHYLOSIS. 

terior to the joint, as there were a number of fractures with a 
snapping sound. When the osteophytes were broken, the ex- 
tremity could be at once extended and rotated without restraint. 

The limb was extended by weight and pulley, and the hip 
covered with a large bag of pounded ice ; different thicknesses of 
flannel were placed between the ice and his skin according to his 
comfort. Yery slight reaction followed the operation. The ex- 
tension was kept up by weight and pulley in bed for four weeks ; 
after that the hip-splint was worn, which enabled him to exercise 
in the open air with only the assistance of a cane. Four months 
after the operation he could walk well without any assistance. 
The motions of his joint were quite free and almost natural, and 
the limb was of its normal length, as seen in Fig. 247, from pho- 
tograph, showing that there could not have been any destructive 
inflammation or loss of substance in the bones. 

Case. Reflex Contractions of Flexor and Adductor Muscles 
of Left Thigh, producing Deformity, simulating Luxation in 
Lschiatic Notch, and complicated with Fibrous Anchylosis, suc- 
cessfully treated by Subcutaneous Tenotomy and Brisement Force. 
— C. K., aged twenty-four, single, native of New York ; teamster 
for hardware-store; admitted to Bellevue Hospital, January 4, 
1872, with the following history : 

About the middle of January, 1871, while attempting to lift 
a barrel of nails into his wagon, he felt something give way low 
down his back, and at the same time a severe pain inside both 
hip-joints and groins, but most severe on the left side. This was 
followed in a few weeks by a bubo or swelling in each groin, 
and, as he had a slight urethral discharge at this time, it was sus- 
pected they were sympathetic with this difficulty, as no mention 
was made to his then attending physician of the previous muscu- 
lar strain. 

He was sent to the Strangers' Hospital, March 10, 1871, and 
I am indebted to my friend Dr. F. N. Otis, one of the physicians 
of the above hospital, for the following notes copied from their 
case-book : " On admission, the patient was a strong, healthy man. 
In both groins a decided induration exists, slight fluctuation on 
left side with tension. March 12th, abscess in left groin opened ; 
very little pus and some blood discharged. March 13th, opening 
was enlarged to prevent burrowing, and bubo stuffed with cotton 
[my italics]. March 15th, tenderness in scrotum on left side, with 



CASE. 421 

hard swelling extending from external abdominal ring to the 
outer side of the vas deferens, and just over the left cms of the 
penis ; very painful to the touch, but giving no impulse when 
coughing, and slightly movable. March 31st, explorative opera- 
tion performed by Dr. Otis, Drs. Bumstead, Sands, and Sabine, 
present. A straight incision was made through the scrotum 
on the left side, and the mass fairly exposed. It was found to be 
closely connected with a hernia above, from which it was detached 
by the scalpel ; the mass was hard, and at the same time very fri- 
able; the finger penetrated it without much resistance, and on so 
doing a little pus escaped. A piece of the mass an inch long was 
reserved for examination and found to be non-malignant. The 
wound was stuffed with lint." The daily record of the case is very 
interesting, but too tedious to be inserted here. I can only sum it 
up by saying that he had excessive suppuration, hectic fever, and 
great prostration, followed in a few weeks by severe muscular 
contractions, and on the 25th of April the notes state that " the 
thigh is drawn up at right angles to the body ; he is unable to 
relieve it ; motion in knee perfect." Extension was applied at 
various times with different weights, but could not be borne on 
account of pain produced. June 1st, the notes state " sinus has 
healed; his condition is pitiful, being unable to extend the left 
thigh and leg, which is still bent at an angle of 100° with the body, 
and also adducted so that the knee points out to the right side." 
An extensive slough formed over the left trochanter major owing 
to the extreme pressure of it against the soft parts, from the 
strong adduction of the thigh. October 17th, " sinus has finally 
healed ; patient as strong as ever. There is great deformity of 
the left lower extremity ; whole pelvis is oblique, left side being 
the highest ; the thigh still flexed, but not so much as previously, 
and is drawn over to the opposite side. There is tonic contrac- 
tion of the adductors, flexor and hamstring muscles, much more 
marked in the former. Discharged." 

When he presented himself at Bellevue Hospital, he was care- 
fully sketched by Dr. Leroy M. Yale, from which the engraving 
was made. (See Fig. 218!) His limb could be drawn nearly paral- 
lel with the other, but it was done by rotating the entire pelvis on 
the opposite acetabulum, and raising the crest of the left ilium 
nearly four inches higher than the opposite side. 

January 10, 1872. — I operated in the amphitheatre of Bellevue, 



422 



ANCHYLOSIS. 



in the presence of a large class, and a number of physicians of the 
city, among them Drs. J. C. ISTott, Mcllvaine, Henry, and others. 
My house-surgeon, Dr. Cushing, had previously fitted to the right 
side of his body a plaster-of-Paris model, extending from his 
axilla to the foot for the purpose of counter-extension, when the 
abduction should be applied after the operation. 

Ether was administered by Dr. Yale, when I divided the gra- 
cilis and the adductors subcutaneously, closed the wound with 
adhesive plaster, and applied a figure-of-8 roller. Then, laying 
him on his back and placing my knees on either ilium to hold his 
pelvis, I forcibly broke up the remaining adhesions and succeeded 
in bringing the limb into position. Adhesive plaster for exten- 
sion was secured to the whole limb by roller, and the plaster-of- 
Paris mould fastened to the right side of the body and leg by an- 
other roller. The patient was then secured in bed, and extension 




Fig. 248. 



Fig. 249. 



Fig. 250. 



and abduction kept up by weight and pulley. Ice-bags were ap- 
plied around the hip. 

The wound healed without any suppuration, and no unpleasant 
symptoms followed the operation. 

February 22, 1872.— Patient walked from my office to the 



ANCHYLOSIS. 423 

photographer's, and had Figs. 249 and 250 taken, which show his 
present position, as well as his power of motion, particularly his 
ability to flex and abduct. 



LECTUEE XXYIII. 

ANCHYLOSIS (CONTINUED). 

Bony or True Anchylosis. — Operation when present at the Hip-Joint. — Cases. — Bony 
Anchylosis at the Knee-Joint. — At the Elbow-Joint. — Case. 

Gentlemen: At my last lecture I gave you the symptoms 
and treatment of false, or fibrous, anchylosis. I will this morn- 
ing invite your attention to the symptoms and treatment of bony, 
or true anchylosis. 

In cases of complete, or bony anchylosis, the deformity is 
sometimes so great as to require correction. To accomplish this, 
section with the saw is absolutely necessary. 

We will first study bony anchylosis as it occurs at the hip- 
joint. 

It is well known that Dr. Rhea Barton, of Philadelphia, first 
operated for the relief of a deformity of this kind in 1826, and 
his operation was followed by a perfect result. He operated by 
making a V-section in the shaft of the bone, and thus bring- 
ing the leg from that point down parallel with the other, and ob- 
taining an improved position. The late Dr. J. Kearney Rogers, 
of this city, repeated this operation in another case, only higher 
up on the shaft of the bone, with equally good results. I modified 
Barton's operation in 1862, by making a curved section of the 
femur above the trochanter minor, and a straight section a few 
lines below the first curved cut, thus removing a block of bone. 

My object was to go above the trochanter minor, so as to 
retain the insertion of the psoas magnus and iliacus internus 
muscles attached to the lower fragment for the purpose of flexion ; 
and by cutting out a semicircular piece thus, o, with its con- 
cavity downward, and then rounding off the upper end of the 
lower section, I would more nearly imitate the natural joint, and 



424 ANCHYLOSIS. 

give the patient a fair chance for motion at that point, with less 
danger of the parts slipping by each other when he walked than 
there wonld be if I cut out a parallelogram or a V-shaped piece. 

This operation I have made in two cases, and both resulted in 
perfect success. The first case is still living. The other case died 
of another disease some months after the operation, but lived long 
enough for Nature to make an entirely new joint with capsular 
ligament, synovial membrane, and a double ligamentum teres, 
which is seen in the specimen before you. (See Fig. 262.) 

Mr. Adams, of London, has very much simplified this opera- 
tion by making a simple subcutaneous single section through the 
neck of the femur in these angular deformities of the hip, with 
very satisfactory results. Dr. Sands, of this city, has repeated Dr. 
Adams's operation, with the result of a movable joint. Reasoning 
a priori, I would suppose that by the single section through the 
bone, although you might by it remove the deformity, you would 
be in danger of effecting a cure by anchylosis. The case of Dr. 
Sands, and some of those reported by Dr. Adams, seem to dis- 
prove this position, but sufficient time has hardly elapsed to judge 
whether they may not after a while become anchylosed, although 
in an improved position. 

The plan of my operation is fully given and illustrated in 
connection with the two cases here appended : 

Case. Anchylosis of both Hip- Joints ; Tenotomy and Brise- 
ment Force in one, and in the other Exsection of Semicircular 
Segment of Bone above Trochanter Minor / Recovery with Arti- 
ficial Joint. — Robert Anderson, native of Lexington, Kentucky, 
age twenty-six, was admitted into Bellevue Hospital in May, 1862, 
and gave the following history of himself : During the summer 
of 1849, when fourteen years of age, he was accustomed to go in 
the river every evening to swim, and on one occasion remained 
in the water some hours, having previously taken very severe 
exercise in running and jumping. 

About the middle of September he was taken with a dull pain 
in the right hip, which continued about one week, so gradually 
and imperceptibly developed that the exact date of commence- 
ment is not known. During this time he continued in attend- 
ance at school, and enjoyed the usual sports and games of his 
schoolmates. One day, after having exercised more freely than 
usual, he was attacked with fever, and .the following day stupor 



CASE. 425 

set in, which lasted nearly three weeks, with the exception of 
intervals ; when aroused by the family, was totally indifferent to 
anything that transpired around him, except when thus diverted 
by his friends. All this time he suffered intense pain in the right 
hip, which was sharp and lancinating. The hip was red, hot, and 
greatly swollen, which extended half-way to the knee. 

At the end of a month the swelling had much subsided, and 
the pain very greatly diminished, though when moved it was still 
very intense- — of the same character felt in the hip, and never at 
the knee. 

About this time began to have pain in hip-joint of left side, 
and also in the knee, which was dull, and never of that sharp, 
lancinating nature which he suffered in the other joint. This 
continued two months. 

Ten days after the commencement of the disease, pillows were 
placed under his knees to relieve the pain. These were increased 
in thickness and continued all the time he remained in bed, which 
was six months ; also during the next six months, whenever he 
was in bed ; but during this latter period he sat up occasionally 
in a chair. From the position assumed during this prolonged 
confinement, the legs were flexed upon the thighs, and the thighs 
upon the pelvis, and have been immovably fixed in that position 
ever since. Had occasional pains all this time in both hips, but 
most severe in the right. 

At the end of two years from date of attack, an abscess formed 
in left groin, which remained and discharged pus for two years. 
Abscesses also formed about the right hip ; one beneath the gluteal 
muscle, and another near the anus. These discharged very freely, 
and continued open for nearly a year and a half. 

At the end of the first year, began to use crutches — compelled 
to use them ever since. For the last six or eight years, general 
health has been perfectly good. 

On admission he had anchylosis of both hips in the position 
seen in the figures 251 and 252, from photographs. 

The left thigh was -immovably fixed at nearly a right angle 
with the pelvis, by bony cementation, or true anchylosis. The 
right was very firmly attached at an angle not quite so acute, and 
by a very careful examination I thought some slight motion could 
be detected, which indicated that the attachments were fibrous in 
character, or at most were osteophytes only, and external to the 



426 



ANCHYLOSIS. 



joint, and that there was no agglutination between the femoral 
head and the acetabulum, whereas the opposite side seemed per- 
fectly cemented together. He could not walk, except by whirling 
himself in semicircles, first on one leg as a pivot, and then the 
other— or else by swinging himself on his crutches from the axilla. 
In order to get both feet upon the ground at the same time, his 
back was curved inward very much at the sacro -lumbar junction, 
the left knee flexed at an angle about forty-five degrees with the 





Fig. 251. 



Fig. 252, 



thigh, and the right side of the pelvis was some inches higher 
than the left. He could only sit by assuming a most awkward 
posture, half-reclining on his side upon a couch or sofa ; and, in 
lying down, was curled up either on one side or the other, or, if 
upon his back, he had to be supported by pillows under his knees, 
and under the lumbar vertebrae. In fact, he was the most pitiable 
object I ever saw, and one that would excite the sympathy of any 
surgeon. 

On the 4th of May, I divided subcutaneously the adductor 
muscles, the rectus, tensor vaginae femoris, and femoral fascia of 
the right hip, and, breaking up the adhesions by some consider- 
able force, obtained very good motion of the joint. Extension 
was made to the limb by a weight and pulley, and the hip envel- 
oped in cloths wet in cold water ; no serious trouble followed the 



OPERATION FOR ARTIFICIAL HIP-JOINT, 



427 




operation, and in six weeks he could flex and extend, abduct and 
adduct his right limb with considerable freedom. 

On the 11th of June, 1862, I removed a semicircular segment 
of bone above the trochanter minor of the left femur, for the 
purpose of establishing a new joint. Drs. I. P. Batchelder, 
Woodhull, and Osborne, of this city, Drs. Hooker, of New Haven, 
Connecticut, Hichborne, of Massachusetts, and Dr. James S. 
Green, of Elizabeth, N. J., were present at the operation. 

The plan of this operation will be seen in the annexed figure 
(253). 

The description of the operation and 
notes of the case are taken from the hospi- 
tal records, which were kept by Dr. Shaw, 
house-surgeon at that time, and at present 
in the United States Navy: 

"An incision of about six inches was 
made over the trochanter major, in the 
axis of the limb. The cut was slightly lu- 
nate, with the concavity looking downward. 
The lips were then separated, and the deeper 
structures, including the periosteum, were 
detached from the bone. 

" A curved instrument, armed with the 
chain-saw, was passed around the bone be- 
tween the trochanters, and the femur first 
sawn transversely across. A roof-shaped 
piece was then sawn out of the upper frag- 
ment. 1 The limb was then put upon moderate traction, longi- 
tudinal and lateral ; the margins of the wound approximated by 
adhesive straps, and cold dressings applied. 

"June l§th. — Wound begins to suppurate, and looks very 
well ; no constitutional excitement. 

" 16th. — He has considerable pain in the limb, and has been 
unable to sleep. Relieved by increase of extension. 

" 20th. — Patient finds that pain is relieved sometimes by less 
extension. 

" July ith. — He has less pain ; purulent discharge free. 

" September 1st. — Since last report patient has experienced no 

1 In my second operation, I sawed the curved section first, and should advise the 
operation to be performed in that way, for reasons which are there given. 



Fig. 253. 

1, head of femur; 2, trochan- 
ter major ; o, trochanter minor ; 
4, line of insertion of capsular 
ligament (variable); 5, tendon 
of psoas mag. and iliacus inter- 
ims muscle ; 6, line of curved 
section; 7, line of transverse 
section; 8,8, dotted lines indi- 
cating rounding off of lower 
fragment after removal of the 
segment. 



428 ANCHYLOSIS. 

untoward symptoms ; discharge from wound is now very slight. 
All 'extension is removed, and he begins to sit up. General con- 
dition very good, and has improved very much in flesh since 
admission. 

" October 12th. — Since last report patient has been walking 
around the hospital on crutches, which had to be lengthened seven 
inches, as he is that much taller than he was before the operation 
and is now quite straight, except the lateral curvature of the 
lower lumbar vertebrae, which raises one side of his pelvis more 
than the other, and makes the right leg apparently shorter than 
the one from which the segment of bone was removed ; but this 
is easily rectified by a higher heel on that side. He can sit down 
in a chair, and get up without assistance, except such as he ob- 
tains from his crutches. To-day he walked into the amphitheatre 
by the aid of his crutches, and exhibited himself to the class, and 
left the institution well, and with very good motion at both hip- 
joints." 

About three weeks after he left the hospital, he was attacked 
with acute pain in the region of the wound, which became in- 
flamed, and soon suppurated. In a few days a small semicircu- 
lar piece of bone came away, and four days after another similar 
piece ; the two together making almost a ring, and seemed to be 
exfoliations from the lower fragment. All the pain immediately 
left him, and the wound healed in a very short time. 

Mr. Anderson remained in the city until late in December, 
when he left very unexpectedly for Kentucky. 

The night before he left he walked to my office, and could go up 
and down the steps without any difficulty ; could stand on either 
leg without crutch or cane ; could take a step with either foot 
twenty-seven inches, and, when he supported his body on his 
crutches, could abduct his legs so that his heels were thirty-six 
inches apart. He could cross either leg over the other below the 
knee, without assistance, but could not cross them upon the thigh. 

The following extract is from a letter of his, dated the 20th 
of January, 1863 : 

"My leg is getting on famously, since I came to Kentucky. 
The first day after leaving New York I grew very tired, but con- 
tinued night and day until we arrived at Cincinnati. I believe that 
when I got to Cincinnati I was fresher than when I started. We 
were in the city about half a day, and then came on to Lexington, 



CASE. 429 

staid all night, and again resumed our journey. So far from 
being exhausted ,at the end of the trip, I started next morning 
in a buggy and drove some twenty miles. I think, if I had been 
compelled to travel a thousand miles before stopping, I could 
almost have danced a jig at the termination of the trip. But to 
speak seriously, I think I am doing very well indeed, and my leg 
gains strength continually.'' 




Fig. 264. 



Fig. 254 is engraved from a carte-de-vis ite, which was received 
in a letter dated Spring Station, Woodford County, Kentucky, 
April 11, 1863, in which letter he states : "I can now 'rough it' 
a little without apprehension of having to suffer for it afterward. 
I can bear my whole weight on my left leg without inconven- 
ience, and can walk very well without other assistance than a 
walking-stick, and the improvement is as great in a month now, 
as at any previous time." 

Case. Anchylosis of Left Hip, Section of Elliptical Seg- 
ment of Femur above Trochanter Minor ; Recovery, with False 
Joint and Good Motion. — Miss Susan M. Losee, of Buffalo, New 
York, aged twenty-four, of healthy parents and of a robust and 
vigorous constitution, was attacked with pneumonia in March, 
1856 ; attended by Dr. F. H. Hamilton. After three weeks went 



430 ANCHYLOSIS. 

down-stairs, contrary to the advice of her physician, and the fol- 
lowing day was attacked with intense pain in the left hip and 
thigh, which was constant, persistent, and most severe for several 
months. She did not fall or receive any injury that she was aware 
of, but it was supposed that she must have wrenched her hip in some 
way going down-stairs, as she was very weak and went down with- 
out any assistance. During the first few weeks her leg was 
straight and could not be flexed, abducted or adducted without 
intense suffering. Bed-sores by this time had become so exten- 
sive as to make it imperative to change her position, and in doing 
this her limb was forcibly flexed at the knee and hip,. but with 
the most intense pain ; and when flexed in this position it could 
not be extended again without the greatest suffering, and was 
therefore permitted to remain in the flexed posture. 

New sloughs appearing over the right trochanter, she was 
placed in a large chair and was not removed for two months, when 
sloughing occurred over the tuber ischii, and at the extremity of 
the coccyx, and she was again compelled to assume the horizontal 
position, and, being forced to lie upon the right side, the left thigh 
was thrown over the right, in a flexed position, and thus became 
permanently and perfectly anchylosed, at the expiration of about 
seven months from the commencement of the disease. 

No local application was made to the hip, but the pain and 
constitutional difficulty were combated principally by morphine, 
and no extension was applied to prevent the muscular contraction 
and deformity. When she recovered, her left thigh was perma- 
nently flexed, at about forty degrees with the pelvis, and strongly 
adducted across the lower third of the right thigh, as seen in the 
accompanying drawings, which were taken from life. Fig. 255 
represents her standing ; Fig. 256 in the act of walking. 

In the erect posture, the heel of the left foot was ten and a 
half inches from the floor, and on the right side of the right leg. 
In attempting to walk, it was brought to the floor, still on the 
right side of the opposite limb, or cross-legged ; and was made to 
reach the floor by a remarkable curvature forward of the lumbar 
portion of the spinal column; but walking was attended with 
great fatigue, and a peculiar dull pain in the lumbar region. Uri- 
nation produced constant excoriation of the limbs, requiring great 
care and trouble in drawing a handkerchief or soft rag between 
the closely-compressed thighs, to keep them clean and comfort- 



CASE. 431 

able. Several efforts were made to insert a catheter, in order that 
the urine might be led off without irritating her limbs ; but it was 
impossible to insert the finger so as to reach the orifice of the 




Fig. 255. Fig. 256. 

urethra, either from the anterior or posterior position, although 
every effort was made, and with great perseverance. 

She remained in this condition until the 6th of November, 
1862, seven years. She came to New York and placed herself 
under the care of Dr. C. F. Taylor, in the fall of 1861, who 
thought the anchylosis was simply fibrous, and capable of being 
relieved by passive movements. Dr. Yan Buren saw her at this 
time, and diagnosticated the case as one of true bony anchylosis. 
I saw her in April, 1862, in consultation with Drs. Taylor, Peaslee, 
and E. Lee Jones, and confirmed the diagnosis of Dr. Yan Buren ; 
but it was thought by all present that I might possibly break up 
the adhesions if I preceded the attempt by section of the tendons 
of the contracted muscles. 

Accordingly, on the 10th of April, assisted by Drs. Peaslee, 
Taylor, and Jones, I divided, subcutaneously, the adductors longns 
and magnus, the gracilis and pectineus, the rectus, sartorius and 
tensor vaginae femoris, and immediately closed the wounds with 
adhesive plaster, and applied a firm roller. No haemorrhage fol- 
lowed the operation. The pelvis was then firmly secured, and 
every effort was made to give motion to the joint, that was con- 
sistent with safety or prudence, but without the slightest benefit 



432 ANCHYLOSIS. 

whatever, and we were all satisfied that an entire section of the 
bone by the saw was the only way that the limb could be moved 
from its flexed and fixed position. The patient was under the full 
influence of chloroform, administered by Dr. Jones, and was 
entirely insensible during the whole operation. The wounds 
healed kindly in a few days, without suppuration, and she was then 
in exactly the same condition as she was previous to the opera- 
tion. As the weather was getting warm, I determined to leave 
her until fall, and then make a section of the bone above the 
trochanter minor, and give her a chance to form an artificial joint, 
similar to Anderson's case. 

On the 6th November, 1862, assisted by Profs. Peaslee and 
Raphael, and in the presence of Dr. J. P. Batch elder and Mr. 
Doane, medical student, I performed the following operation : The 
patient having been put under the full influence of chloroform, a 
longitudinal incision six inches in length was made over the tro- 
chanter major, commencing just above its crest, and as near as 
possible to its centre, and carried directly down to the bone. 
About the centre of the incision I made another at right angles to 
it, in the posterior flap, but only carried it through the tegument- 
ary and adipose tissue and the femoral fascia. The blade of the 
knife was then laid aside, and, with its handle and an elevator some- 
thing like an ordinary oyster-knife, I carefully peeled off the 
attachments from the bone, on its anterior surface, until my fore- 
finger could reach the trochanter minor in front. The same thing- 
was then done on the posterior surface of the bone, and the two 
fingers could then surround the bone, with the exception of a thin, 
firm fascia, between them on the front. This was readily pierced 
by a steel sound, curved to fit the femur, at this part, and a chain- 
saw was then drawn through above the trochanter minor, which 
could be distinctly felt and was my guide. 

About half an inch above it I commenced to saw, and carrying 
it first upward and outward, then outward, and then downward 
and outward, I made a curved section with its concavity down- 
ward, thus /^~~^\ - 1 The saw was again passed around the bone, 

1 It will be seen that in this case I reversed the order of the section of the bone 
from what I did in Anderson's case, and made the curved section first, and I should 
advise the operation to be performed in this way, as it is much easier, and you are 
more certain to make your saw enter at the part desired when the shaft is complete, 
besides having the limb to keep the parts steady while the section is made. And, as 



CASE. 433 

as at first, and inserted about an eighth of an inch below the first 
section and the. bone sawed square off, at right angles with the 
long diameter of the bone. The segment thus removed was 
one-eighth of an inch in front or internal margin, three-fourths 
at its middle, and nearly half an inch at its external margin, as 
seen in Fig. 257. 

The bone was very dense in texture, almost eburhated, as seen 
in Fig. 258, which represents the lower section. 





Fig. 257. Fig. 258.— View of Lower Surface. 

There was not more than two ounces of blood lost in the op- 
eration, and no ligature was necessary. 

The wound was brought together by two sutures and adhesive 
plasters, except the posterior incision, which was kept open by a 
tent of oakum. Adhesive plaster was applied below the knee, 
for the purpose of making extension, and a roller applied toler- 
ably firm, from the toes up, over the entire limb, and around the 
pelvis. 

She was then put in bed, the foot of which was raised some 
twelve inches higher than the head, and a pulley applied, over 
which a weight was attached by a cord to the adhesive plaster, 
for extension, the same as in a case of fracture of the thigh. 
Lateral extension was also applied to the upper portion of the 
thigh, to keep the upper end of the femur from crowding against 
the femoral vessels, by means of a broad band passed around the 
thigh and a cord attached to its outer aspect, which played through 
a pulley fixed in an upright by the side of the bed, just below the 
pelvis, and a weight attached. By this means the limb was 
brought in its natural position, parallel with the other and ap- 

it requires some little delicacy of manipulation to carry a chain saw in this position 
in the curve required, it is well not to add to the complication by having a movable 
bone. 

It may be asked, why not make both sections curved ? Because it is so difficult to 
do it with accuracy, when one end of the bone is movable, and, as the rounding off of 
the lower section is more simple and equally satisfactory, I prefer it. 
28 



434 ANCHYLOSIS. 

parently of the same length. Ten drops of morphine were given, 
with instructions to repeat if necessary. 

The following record of the case is an abstract from my note- 
book : 

November 17th. — Has had a very comfortable night ; urinated 
without scalding her limbs, for the first time in seven years. No 
haemorrhage, or much heat of limb ; pulse 94 ; complains of pain 
in the back, otherwise perfectly well. 

11 p. m. — Pain in the back very severe, just at the lower 
lumbar vertebrae, which is carried very much forward, and can 
only be relieved by being well bolstered up, and by raising the 
head and shoulders almost to the sitting posture. 

18^. — Slept well all night, with only sixty drops of Magendie's 
solution; pulse 94, and only complains of her back, which 
requires to be pressed frequently and quite firmly to make her 
comfortable ; as it was difficult to use a bed-pan, and without it 
the urine soiled the bed and excoriated her person, I drew it by the 
catheter, which can now be inserted without the least difficulty. 

19^. — Wound commencing to suppurate, at the tent, the rest 
of the wound united by first intention ; removed the sutures with- 
out disturbing the adhesive plaster; pulse 94; bowels moved 
naturally, and, with the exception of pain in the lower part of the 
back, feels well. 

December 1st. — No particular change since last report ; sup- 
puration healthy and not profuse. The only complaint she makes 
is from her back, and the difficulty she has in using the bed-pan. 
I put her to-day upon Dr. Nelson's fracture-bed, which is a triple 
inclined plane, with an opening for defecation, and it has made 
her very comfortable indeed ; and the extension was accomplished 
by simply flexing the legs at the knee, over the inclined plane, 
as seen in Figs. 259 and 260. 

This fracture-bed was first constructed by Dr. Eobert Nelson, 
of this city, formerly of Canada, and for convenience and com- 
fort, as well as fulfilling all the indications required, is the most 
perfect contrivance I have ever used, and I cannot speak too 
highly in its favor. 1 

1 In Hesselbach's " Handbuch der Chirurgischen," printed in Jena, 1845, will be 
found an almost exact duplicate of Nelson's bed on plate xxxix., with a description on 
page 1036, as having been constructed by Weckert; but, as Dr. Nelson made his bed 
in 1820, we must give him the preference of priority. 



CASE. 



435 



From the time the patient was placed upon it until she en- 
tirely recovered, a period of nearly four months, she was perfectly 
comfortable ; could be raised or depressed to any desired angle, 
as often as required, without inconvenience, which greatly added 




to her comfort, by the change of position. The wound healed 
entirely within four weeks, except a very small opening in the 
posterior cut, which was at the most dependent position, and from 
which a small discharge of pus escaped ; this discharge gradually 
diminished and finally ceased about the 1st of March, four -months 
after the operation. Two small pieces of bone escaped during 
this time the size of a pin's-head. For some weeks before its 
stoppage the discharge consisted of only a few drops in a day, of 
a very peculiarly whitish-yellow semi-fluid, of the consistency of 
thick starch-water, and upon examination proved to be nearly pure 
albumen. 




Fig. 260.— Dr. kelson's Fracture-Bed. 



436 ANCHYLOSIS. 

After the first ten days from the operation I made slight move- 
ments of the limb very frequently, in order to prevent anchylosis, 
and this was also accomplished by the extension, which kept the 
severed bones from coming in contact with each other, and thus 
prevented osseous adhesion. 

I gradually increased the extent of these motions, until, about 
the 1st of February, I could flex and extend, rotate, adduct and 
abduct the limb with almost the freedom of a natural joint, and 
could also press the bones together with considerable force with- 
out pain. 

On the 8th of February, 1863, she got out of bed for the first 
time — the limbs are perfectly symmetrical and parallel — the left 
nearly three-quarters of an inch shorter than the right, when her 
weight is put upon it ; but, when she stands erect upon the other 
limb, it falls down, and is nearly if not quite as long as its fellow. 
By pressing it up you can shorten it a full half-inch, and by con- 
cussion it gives a smooth, cushioned feel to the hands, without 
any crepitus or pain to the patient. 

February 20th. — She begins to have some control over the 



Fig. 261. 



movements of her limb by voluntary muscular contraction, and 
can bear nearly her whole weight upon it, as seen in Fig. 261. 
The motions are nearly as perfect as those of the natural limb. 



CASE. 437 

From the perfect success attending the operation in these two 
cases of true anchylosis, and the freedom from all danger, as well 
as ease of its performance, I feel justified in recommending it to 
the profession as safe, and am satisfied that it will become estab- 
lished as one of the proper operations in surgery. 1 

Sequel. — The patient progressed rapidly and favorably dur- 
ing several weeks, being able to bear her entire weight on the 
affected limb, with perfect freedom in passive motion, and gradual 
increase of control over the voluntary movements. 

She was acquiring sufficient command over the limb to enable 
her, as the result of practice, to walk around her room, the exer- 
cise conducing to the improvement of her general health, as well 
as to the education and development of muscles which had long 
remained dormant ; when, about the 1st of March, in opposition 
to my advice, she removed her flannels. She remained with them 
off for several days, and, on the 4th and 5th of March, being ex- 
posed for some hours to the intense cold then prevailing, she had 
a severe chill, followed by great difficulty in breathing, pain in 
the chest, cough, etc., arising from congestion of the lungs. 

She neglected to send for me at once, and, when she did, I was 
out of town, and she refused other medical attendance. She grew 
worse rapidly, and, when I saw her upon my return, I at once 
recognized her condition as one of extreme danger, and requested 
the presence of Dr. Flint in consultation. 

"We found the left lung had become almost hepatized, and for 
some days no respiration could be detected on that side. Under 
treatment resolution gradually took place, with the exception of 
an abscess in the upper lobe of the left lung, which Dr. Flint 
thought was the result of an apoplectic effusion. Dr. Flint did 
not at this time diagnosticate tubercles, but did at a later period. 

To the pneumonia was superadded, in a short time, pleurisy 
of the left side. The urgent symptoms of the pneumonia were 
subdued, but the cough, which was very distressing, continued. 
There was no expectoration at any time. 

Under a sustaining plan of treatment, with spirits of turpen- 
tine locally over the hepatized lung, she improved, and I was en- 
couraged in'the hope that the abscess might become sacculated, 
and remain circumscribed. 

The weather up to about the middle of April had been too 

1 See Mr. Adams's improvement on my operation, in Lecture on Anchylosis, p. 424. 



438 ANCHYLOSIS. 

inclement to allow her the advantages of passive out-door exer- 
cise, which, together with nourishment, was now considered the 
principal treatment required. 

During all this time the cough had remained of the same rack- 
ing, distressing character, and without expectoration. 

On the 20th of April, she complained of some pain in the 
vicinity of the cicatrix of the wound left by the operation, and 
the lower part of the wound became inflamed and puffed out, 
although it had been closed several weeks. 

On the 22d, an abscess having formed, the wound opened, and 
a small curved piece of bone escaped, about one-eighth of an inch 
long, and of the thickness of an ordinary probe, quite rough and 
jagged. 

The wound discharged a little bloody pus for a few days, after 
which it gradually merged into the same kind of oily fluid as had 
exuded during some months subsequent to the operation. 

This, in a few more days, began to diminish, and gradually the 
wound again closed, leaving no tenderness upon pressure, or mo- 
tion of the new joint. 

She could again bear her whole weight upon the limb without 
inconvenience, and her command of its movements materially 
improved. 

About the 1st of May she changed her residence, and for a 
number of days improved rapidly in strength and flesh, the prin- 
cipal annoyance being the cough. 

On the 10th of May, having business out of town, I left the 
case in charge of Dr. Flint, w T ho prescribed, for the cough, codeia, 
four grains, to simple syrup, four ounces, with directions to the 
nurse to give the patient a teaspoonful once in three hours while 
the patient remained awake, but to discontinue it while she slept. 

During the night, as the result of larger and more frequently 
repeated doses of this mixture than had been ordered — which ap- 
peared from the admission of the nurse, and the small quantity 
left in the bottle — the patient had become thoroughly narcotized, 
and subsequently suffered, for more than forty-eight hours, with 
most alarming symptoms of narcotic poisoning. 

The utmost exertions on the part of Drs. Flint, Peaslee, and 
Wells, were required to sustain life, in consequence of the stomach 
rejecting stimulants, coffee, etc. 

The cough had now entirely ceased, and never returned. 



CASE. 439 

Great distress in the lungs was complained of, and partially 
relieved by connter-irritants. The stomach continued so weak as 
not to retain even a teaspoonful of iced water. 

On the 12th she had recovered from the severe symptoms, 
when a relapse occurred from the administration of another dose 
of the codeia, in direct violation of orders that no more should be 
given, which it seems were misunderstood by the nurse. During 
the night the patient was violently delirious, her screams arousing 
and disturbing the household until morning, when Dr. Wells 
administered, by inhalation, a small quantity of chloroform, 
which at once calmed the patient, and she slept for several hours. 

I returned on the 13th, and found her still in a wild and dis- 
tracted state of mind, and excessively prostrated, the stomach not 
having retained anything for several days. 

The process of nutrition was necessarily suspended, and the 
patient was dying in consequence. 

The stomach had lost all tone as the result of protracted nar- 
cotism, induced carelessly, but with humane intent, and she was 
now sustained by enema. 

On the 14th she had rallied, and become quite cheerful, but 
had no recollection of the terrible ordeal through which she had 
passed. Later in the day, while I was sitting by her bed, she 
suddenly had two severe convulsions, during which her lower 
limbs were flexed at a right angle, and strongly adducted, the left 
one requiring almost as much force to straighten as the right. 

The nurse stated that the patient had had a similar fit during 
the preceding night, the limbs being fixed in the same manner 
for a long time, and that when the spasm passed off she volun- 
tarily straightened her limbs. 

On the 16th she sat up about an hour, and, after getting back 
in bed, discovered that the wound had again opened and dis- 
charged a few drops of bloody serum. 

She passed a remarkably good night, and on the following day 
felt so much better that she begged me to allow her to take a ride 
the next day. 

I tried to persuade her that she was too weak, but she was 
quite importunate, and after I had left, in order to test her strength 
in view of the anticipated ride, she got out of bed, and sat up in 
a chair for two hours. 

The exertion was too much, and she fainted. 



440 ANCHYLOSIS. 

I was hurriedly summoned, and found her cold and pulseless, 
except at the carotids. Pupils much dilated ; jaws relaxed ; respi- 
ration very feeble and slow ; unable to swallow. Brandy was 
given in enema, but not retained. 

She gradually recovered consciousness and ability to talk, which 
she did rationally, but grew weaker and weaker until about six 
p. m., on the 17th, when she died from exhaustion. 

Post-Mortem. — An examination of the body was made about 
thirty-six hours after death, in the presence of Profs. Bush, of 
Lexington, Kentucky ; Parker and .Raphael, of New York ; and 




Fig. 262.— a, a, a, a, capsular ligament opened and reflected; I, &, round ligament in imitation of 
ligamentum teres ; c, articulating head of lower section, covered with cartilage ; d, d, new 
acetabulum, covered with cartilage ; both lined with synovial membrane. 

Drs. Spencer, of Watertown; Batchelder, Dewees, Stone, Ber- 
nachi, Elsburg, "Wells, Swift, Doyle, and Peck, of New York. 

The body was extremely emaciated ; the left leg being parallel 
with the right, the foot lying in the natural position, and was 



CASE. 



441 



found to be half an inch shorter, and admitted of free, passive 
motion in all directions without crepitation. Upon opening the 
thorax, adhesions were noticed of various portions of the pleura 
and lungs, and a large abscess in the anterior portion of the upper 
lobe of the left lung. Two quite small abscesses were found in 
the lower lobe of the right lung, but neither of them communi- 
cated with the bronchi. 

There was infiltration of deposit throughout the substance of 
the upper lobe of the left lung, which, under the microscope, was 
determined by Dr. Dewees to be tuberculous. 

Upon examination of the artificial joint, it was found to be 
provided with a complete capsular ligament, and the articulating 
surfaces were tipped with cartilage, and furnished with synovial 
membrane. (See Fig. 262.) 

There was a very small spicula of bone, which had exfoliated 
from the lower section in the orifice of the external wound, and 
which would have escaped in a few days. Four other small 
fibrillse of bone, about one-half inch in length, and the thickness 
of the lead of an ordinary pencil, were found attached at one of 
their extremities, by periosteum, to the margin of the new head 
of the femur ; their free extremities were thrust into the tissue 
around the joint. They were easily pulled off, having nearly 




exfoliated, and doubtless would have come away as the other 
pieces had done, had the patient lived. 

All the other parts of the head and the new acetabulum were 
smooth, and covered with cartilage. 

The conjunction of the articulating surfaces was perfected by 



442 



ANCHYLOSIS. 



the formation of two round ligaments springing from the surface 
of the new acetabulum, and, by their convergence at the same 
point of attachment to the new caput femoris, formed a new liga- 
mentum teres. 

These converging portions of the ligament were fan-shaped, 
and united at the sulcus of the new head of the femur. 

A portion of the ilium, together with the cotyloid cavity, con- 
taining the anchylosed head of the femur was removed, and, upon 
section through the original acetabulum and caput femoris, only 
a slight line of demarkation was discoverable, the whole joint 
being fused into one solid bony mass. (See Fig. 263.) 

Dr. Austin Flint, Jr., examined the specimen by the micro- 
scope, and reports that the lining is true cartilage, and it is there- 
fore as perfect in all its physiological characters as any natural 
joint. 

The annexed diagram (Fig. 264) shows the cartilage, cavities 
and cells, as taken by Dr. Flint under the microscope, from the 
artificial joint of Miss Losee. 

With respect to the case of Miss Losee, Bauer, in his work 
upon " Orthopedic Surgery," published by William Wood & Co., 
1868, misstated the facts concerning the appearances found at 




Fig. 264.— Cartilage, Cavities and Cells : A, cartilage, cavities without cells ; B, cartilage, cavi- 
ties and cells. 

the post mortem. ■ On pages 234 and 235 of his work may be 
found the following statement : 

" True bony anchylosis of the hip-joint finds its relief in 



CASE. US 

Bhea Barton's operation. I have never had occasion to perform 
it, and can therefore offer no suggestions drawn from personal 
experience, but it would seem to me that the attempt at estab- 
lishing an artificial joint at the line of division is unattainable for 
two reasons : 1. An artificial joint could never give a sufficient 
support to the superstructure of the body ; 2. It inevitably pro- 
tracts the suppuration, with its impending danger of pygemia. 
Sayre a few years ago performed this operation, as he alleged, 
with success, but his patient nevertheless died a few months after 
of pysemia. 

" The specimen derived from the case did not sustain the as- 
sertion of that gentleman; no cartilaginous covering, synovial 
lining, or a new capsular ligament, having been formed." 

I have taken pains to secure letters from every gentleman who 
was present at the post-mortem examination, with the exception 
of two who are dead, and they all concur in the statement that 
there was mobility, and that a false joint was formed at the point 
where section of the bone was made. 

The following letters, however, from Dr. Doyle, Dr. Austin 
Flint, Jr., Prof. Parker, and Dr. Bush, Professor of Surgery in 
Transylvania University, I regard as all that are necessary to 
publish in this place to correct any misapprehension that may 
have been entertained with reference to the actual results of that 
operation. The letters of all the other gentlemen have already 
been published in the New York Medical Journal for January, 
1869. 

" Bixghahton-, New York, April 24, 1868. 
"Peof. Sayee — 

"Deae Sie: In perusing the work of Dr. Bauer on orthopedic surgery I 
was somewhat surprised to read there (page 285) as follows : ' Sayre a few 
years ago performed this operation ' (artificial hip-joint), ' as he alleged with 
success, although his patient died shortly after with pyaemia. The specimen 
derived from the case did not prove the assertion of that gentleman ; no car- 
tilaginous covering, synovial lining, or capsular ligament, having been formed.' 
The quotation refers to the case of Miss Losee. 

" As I frequently saw the patient and took a personal interest in her case, 
I feel it my duty to disabuse the public of the false impression which his state- 
ments are likely to produce. You can, therefore, if you deem it proper, pub- 
lish the following facts, to which I can clearly testify : Miss Susan M. Losee, 
on whom you performed the operation for artificial hip-joint, was seen by 
me several times during the month previous to her decease. As far as the 
operation was concerned, it seemed in every way a complete success, but it 



444 ANCHYLOSIS. 

was very evident to me that she was in the last stage of phthisis pulmonalis, 
in consequence of which her death took place on the 17th day of May, 1873. 

" In company with several other medical men, I was present at the autopsy, 
which revealed important facts, which go strongly to sustain not only the 
feasibility, but also the justice of the operation. On opening the thorax, the 
lungs were found to contain a large amount of tuberculous deposit, much of 
which had broken down, leaving several cavities. Our attention was next 
turned to the limb on which the operation had been performed. It was 
found to possess the property of being moved with ease in any direction with- 
out crepitation. The artificial joint was then dissected down to, and was 
found to be provided with a capsule, very much resembling the capsular liga- 
ment of the normal hip-joint, being complete and lined with a synovial sur- 
face. On opening the capsule to get an interior view of the joint, we found 
the articular surfaces covered with cartilage and provided with a double 
ligament, which seemed to answer all the purposes of a veritable ligamentum 
teres. In order to leave no doubt as to the substance on the artificial surfaces 
being true cartilage, a portion of it was examined under the microscope by 
an eminent physiologist of New York, and found to contain cartilage-cells. 

" The ligament was found to be bifurcated, having a single origin in the 
head of the bone, and then separating and finding an insertion at two differ- 
ent points in the new acetabulum. 

"The specimen was taken from the body and I prepared it for preserva- 
tion. I also made drawings of it while fresh, and took it to the photog- 
rapher's and had a picture taken from it, in order, as you remarked at the 
time, that there might be no room for any one to think that the drawings 
were incorrect. 

"Engravings made from the photographs were shortly after published in 
the " Transactions of the Medical Society of the State of New York." 

" Now, the conclusion which I draw from the case in question is this : if 
the operation succeeded so well in a tuberculous subject, how much better 
and more practicable would it have been in a perfectly healthy person ! 

"Dr. Bauer makes great mistakes in his assertions as to there being no 
cartilage, synovial lining, etc. He knows, as every surgeon ought to know, 
that very often cases are met with when artificial joints are accidentally 
formed as a consequence of non-union of fractures, the distal ends and proxi- 
mal extremities being covered with true cartilage. Now, if Nature, under all 
the disadvantages of accidental contingencies, can form a new and nearly 
perfect joint, how much more effective would be her reproductive powers if 
judiciously assisted by the skillful resources of art! 

" In conclusion, then, I feel justified in saying that the case of Miss Losee 
was a success as far as the operation for artificial hip-joint was concerned ; 
and it clearly illustrates the practicability of the operation, and affords a 
precedent for similar operation, which will yet be performed for the relief of 
suffering humanity. 

" I remain, as ever, yours truly, 
(Signed) " Geegoey Doyle." 



CASE. 445 

" Lexington, Kentucky, April 23, 1868. 

" My deae Doctor : Yours of the 14th of April just received. I was 
present with several professional gentlemen, Prof. Parker among the number, 
at the post mortem of your artificial hip case, which proved satisfactoril y that 
the patient died of tubercular consumption. 

" The specimen derived from the case offered a beautiful illustration of arti- 
ficial joint with cartilage, capsular, synovial, and ligamentous structure pro- 
duced by the operations of Nature after surgical skill had prepared the parts. 
You may remember, I pointed out the interarticular ligaments, one of which 
had been separated at one of its attachments, by the too free manipulations 
of the limb by one of the gentlemen present. These interarticular ligaments 
were the most remarkable feature in the development of the joint ; and you 
may not have forgotten my remark to you upon the examination of the speci- 
men subsequently at your office : ' How wonderful and beautiful was Nature 
in this reproduction of even the ligamentum teres, in constructing the new 
hip-joint for your patient, imitating so well the anatomy of the normal articu- 
lation! ' 

" Most truly your friend, 
(Signed) "J. M. Bush." 

"Bellevue Hospital Medical College, April 29, 1868. 
"Prof. Lewis A. Sayre — 

"Dear Sir: In May, 1863, I received from you a specimen of a portion 
of the ilium, with the upper extremity of the femur, taken'from a patient upon 
whom you had operated just below the great trochanter, for the purpose of 
making an artificial hip-joint, being completely and irremediably anchylosed. 
" The patient's name was Susan M. Losee, and she died, as I heard, of tu- 
berculosis some time after the operation. The specimen which I examined 
was the cut end of the femur, with a portion of the pelvic bones, forming a 
new joint. I found this end of the femur incrusted with true articular carti- 
lage, and sent you at the time a report of the microscopical examination, with 
a drawing showing the cartilage, cavities, and cells. 

" Yours very truly, 
(Signed) "A.Flint, Jr." 

"New York, September 27, 1868. 
" Dear Doctor : In reply to your inquiry, I beg to state I was present at 
the examination of the body of Miss L. in the spring of 1863. 

"I made a full examination of the limb operated upon, and the motion 
was free at the new joint. The parts were then laid open; the new joint 
consisted of a firm structure surrounding the point of operation, and made a 
capsular ligament. On opening this capsular ligament the cavity was found 
to be lined by a synovial membrane smooth and lubricated. Between the 
sawed surfaces of the bone an interarticular cartilage and ligament were found. 
The case was of great interest, inasmuch as it verified views which we had 
under discussion. 

"Yours, etc., 
(Signed) " Willard Parker. 

" To Prof. Lewis A. Sayre." 



446 ANCHYLOSIS. 

Knee-Joint. — In bony anchylosis of the knee-joint, unless the 
deformity is snch as demands interference, it is better to let it 
remain undisturbed. 

If the deformity is sufficient to demand operative interference, 
a wedge-shaped piece of bone may be removed of sufficient size 
to permit the limb to be brought into the straight position. 

Dr. G-urdon Buck, of this city, performed this operation in 
the New York Hospital in 1841 or 1842. The operation is per- 
formed in the following manner: Two incisions are made, one 
upon each side of the knee-joint, at the lower border of the con- 
dyles of the femur, and these are connected in the middle by an 
incision over the patella, thus making what is known as the H -in- 
cision. The flaps are then dissected up, and a narrow, leaden 
spatula worked through behind the joint from side to side to pro- 
tect the blood-vessels from injury while the bone is being re- 
moved with the saw. Any small saw may be used, as Butcher's 
or the metacarpal saw, and a V-shaped portion of bone removed, 
of such dimensions as will permit the limb to be brought into the 
straight position. 

Considerable care is necessary in removing this portion of 
bone, in order that it shall be of the exact size required to allow 
the cut surfaces of bone to come squarely in contact with each 
other, and at the same time have the limb straight. If too large 
a section is made, the limb will curve backward, and you will 
produce another deformity by the operation. 

If the adjustment is not sufficiently accurate when the sur- 
faces are brought together, another section of bone must be 
removed. 

In order that the surgeon may remove a portion of bone of 
the exact size requisite to permit restoration of the limb to the 
straight position, it is a good plan to lay a piece of pasteboard or 
paper by the side of the limb, and sketch an outline with a pencil 
while it remains at the angle at which it is to be operated upon. 
Then, by cutting a V-shaped section out of this pattern, which will 
permit of restoring it to the straight position, you can ascertain the 
exact size of the piece of bone to be removed to enable you to 
restore the deformed . limb to the desired position. When the 
bone has been removed, three holes are to be drilled through the 
lower extremity of the femur and upper extremity of the tibia, 
exactly opposite each other, one upon each side and one in the 



CASE. 447 

middle, for the insertion of silver-wire sutures. TVlien the bones 
have been brought together and secured by means of the sutures, 
the whole limb is to be placed in some apparatus, and retained 
there until anchylosis has taken place. In other words, the case 
is to be treated like one of compound fracture. 

The most complete apparatus that can be employed is Butch- 
er's splint, or Dr. Packard's, of Philadelphia, which has been 
fully described when speaking of exsection of the knee-joint. 
(See Figs. 142 and 143.) A very efficient and cheap dressing is a 
firm plaster-of -Paris splint, applied along the posterior aspect of 
the limb. Any fixed apparatus, however, may be employed that 
shall suit the convenience of the surgeon. Dr. Fluhrer, of this 
city, has recently constructed an instrument for retaining the 
limb in a fixed position after section of the knee-joint, which is 
more simple in its application, and at the same time more effica- 
cious, than any other that I have seen applied. Prof. James R. 
Wood has recently employed it with the most satisfactory result. 

Elbow- Joint. — If the elbow-joint has become permanently 
anchylosed at a right angle, an operation for correcting the de- 
formity is not justifiable. If, however, anchylosis has taken place 
with the limb straight, a section of bone of the elbow-joint may 
be removed. For, in such cases, we may reasonably expect to 
obtain mobility at the point of section. 

I perform this operation by making a single straight incision 
over the joint, and, drawing the soft parts aside, expose the bone. 
I then first remove the tip of the olecranon for the purpose of 
retaining the attachment of the triceps muscle, and then saw 
through the humerus, and radius, and ulna. "When the sections 
of bones have been removed, the forearm is to be at once re- 
stored to a right angle with the arm, and the entire limb secured 
in some fixed apparatus until all inflammatory action has sub- 
sided, when passive motions should be commenced. 

In many cases where the elbow has been anchylosed in the 
straight position by improperly-dressed fractures, and the dress- 
ings retained so long as to lose the mobility of the joint, you 
may, possibly, succeed in restoring motion to the joint by re-fract- 
uring it, if done within a reasonable period after consolidation, 
without resorting to any other operation. 

The following case illustrates this fact very well : 

Case.— George TV. G., aged thirteen years, fell from a tree 



M8 



ANCHYLOSIS. 



in April, 1874, fracturing his arm. The gentleman who saw 
him at the time placed his arm in the straight position, and 
secured it in that manner by a board in front of his arm, to 
which it was secured by a roller, and retained in this position for 
seven weeks, at the end of which time firm union had occurred, 
the arm being perfectly straight, but the hand strongly pronated. 
When the dressings were removed, there was very great disap- 
pointment in finding the elbow completely anchylosed. One 
week from that time, eight weeks from the time of the accident, 
he was brought to me with the arm firmly anchylosed in the posi- 
tion seen in Fig. 265 (from a photograph). 

I put him fully under the influence of chloroform, and, with 




Fig. 265. 



some force, succeeded in gradually breaking up the adhesions and 
restoring the arm to an acute angle. The fingers were well 
padded with cotton, and secured with a firmly-adjusted roller. 
The bandage was then carried up the forearm and over the 
elbow, which had been previously padded, and up the arm, a 
piece of sponge having been placed over the brachial artery for 
partial compression. One of Ahl's felt-splints was moulded to 
the arm in this angular position, and retained there. Ice-bags 
were placed around the elbow for several days, and fortunately 
no constitutional disturbance followed. 

At the end of ten days the splint was removed, and the sponge- 
compress taken off. Gentle friction was applied to the limb, 
which was very much ecchymosecl, and very slight passive mo- 



CASE. 4±9 

tion given to the joint under the influence of an anaesthetic, after 
which the arm was re-dressed as before, with the exception of the 
sponge-compress over the brachial artery. 

Two days after, the same manipulations were repeated, with a 
little more freedom of movement. 

Each succeeding day these manipulations were continued, in- 
creasing the movement a trifle each time, for about two weeks. 
An anaesthetic was required each time motion was given to the 
joint. 

From this time onward the dressings were removed daily, and 
manipulations made without the anaesthetic, and, at the end of a 
month, an instrument was adjusted to his arm with a hinge at the 
elbow, and, by means of a ratchet and key, I could obtain flexion 
to an acute angle and perfect extension. The boy was instructed 
how to use the instrument, and was told to apply the key several 
times a day for the purpose of making complete flexion and 
extension, but never carry the movements to the point of pro- 
ducing pain which would last more than twenty-four hours. 

Once or twice during the treatment, slight febrile excitement 
was produced, accompanied with great tenderness and heat over 
the joint, and the motions had to be omitted for two or three 
days, ice and cold water having in the mean time been applied. 




Fig. 266. 



With the exception of this febrile phenomenon, nothing 
occurred in the case worthy of mention, and, at the end of four 
months, he was capable of making perfect extension (as seen in 
29 



450 



FACIAL PARALYSIS. 



Fig. 266), and complete flexion, to an acute angle (as seen in Fig. 
267), both motions being the result of the voluntary contractions 




Fig. 267. 



of his own muscles without mechanical aid. 
are from photographs by O'Xeil.) 



(Figs. 266 and 267 



LECTUKE XXIX. 



VAEIOUS DEFOEMITIES NOT DESCRIBED IN PREVIOUS LECTURES. 



Deformity accompanying Facial Paralysis. — Torticollis. — Disease of the Wrist-Joint. 
— Causes. — Treatment. — Method of making Extension and Counter-Extension at 
the Wrist- Joint. — Case. — Wrist-Drop. — Causes of the Paralysis that gives Rise to 
the Deformity. — Why it gives Rise to this Peculiar Deformity. — Symptoms. — 
Treatment. 

Gentlemen : I invite your attention this morning first to the 
deformity which accompanies facial paralysis. 

The deformity which accompanies paralysis of the facial nerve 
is due to more or less complete loss of muscular power in those 



TORTICOLLIS. 451 

muscles to which the nerve is distributed. The causes of paral- 
ysis of this nerve have been so fully explained in text-books, and 
the peculiarities of the deformity are so well understood, that 
but little time need be spent in their consideration. The most 
common cause of this paralysis, perhaps, is direct exposure to 
cold, such as comes from a current of cold air striking directly 
upon the side of the face. The deformity consists in a drawing 
of the mouth toward the unaffected side ; the patient is unable 
to whistle or laugh properly ; the angle of the mouth upon the 
affected side is lower than normal, and the eye upon the same 
side can be only incompletely closed. 

The deformity not infrequently becomes permanent. 

In many cases, however, so far as the cheek is concerned, it 
can be relieved in a very simple manner. 

The principle is to approximate the origin and insertion of all 
the muscles affected. 

This can be done by bending a hook upon the end of a piece 
of silver wire, and hooking it into the angle of the mouth, and 
then fastening the other extremity by bending it around the ear, 
as suggested by Dr. Detmold. The ear will yield somewhat, 
which may be sufficient to afford all the relaxation desired ; but, 
if it is insufficient, a piece of elastic can be used, with a piece of 
wire attached at each extremity. When the muscles are sup- 
ported in this manner, galvanism can be applied with benefit, for 
the muscles are then able to contract without carrying any 
weight. 

This is a rule that should never be violated, when applying 
galvanism or electricity to paralyzed muscles. 

Torticollis, or Wry-Neck. — This deformity is of quite com- 
mon occurrence. It may be congenital or acquired. "When ac- 
quired, it may depend either upon abnormal muscular contrac- 
tion or upon muscular paralysis. The muscle chiefly involved is 
the sterno-cleido mastoid. When either one of these muscles 
contracts independently of the other, the head is drawn toward 
the shoulder of the same side, and rotated so as to carry the face 
toward the opposite side. 

Again, when one of these muscles becomes paralyzed, and the 
other is permitted to contract without anything to counterbal- 
ance it, wry-neck is the usual result. 

In this respect, therefore, it is similar to the deformity of 



452 



TORTICOLLIS. 



club-foot, and depends upon lack of balance in the contractions 
of opposing muscles. It may also depend upon permanent con- 
tractions of tissue following inflammation. Scrofulous abscess 
upon the neck may be followed by thickening of all the surround- 
ing tissues and sloughing, and the subsequent contractions attend- 
ing the process of cicatrization may give rise to wry-neck. 

The cicatricial contraction following a burn is not an infre- 
quent cause of wry-neck. The deformity, however, which chiefly 
interests us is that produced by irregular muscular contractions, 
due either to paralysis of one sterno-cleido-mastoid muscle or a 
spastic contraction of the other. 

The deformity is frequently established during the process of 
parturition by undue traction made upon the neck of the child. 
The head may become caught at the superior strait of the pelvis, 
and, under such circumstances, undue traction may injure the 
spinal accessory nerve to such an extent as to give rise to subse- 
quent irregular muscular contraction of the two sets of muscles 
upon the sides of the neck. 

The consequences will be, gradual development of this de- 
formity. 

The deformity consists of a peculiar position of the head, that 
is, a rotation of the head upon its axis caused by the approxi- 




Fig. 268. 



mation of the origin and insertion of the sterno-cleido-mastoid 
muscle. 

The chin is elevated, and the rotation of the head brings the 
ear in front of the shoulder upon the affected side, as in the case 



TORTICOLLIS. 453 

now before you. {See Fig. 268.) Ordinarily, the deformity is 
easily recognized. There are, however, certain conditions with 
which it may be confounded. 

It may be mistaken for fracture of the cervical vertebrae. 
This fracture is not of common occurrence, but, when it does 
take place, it is ordinarily fatal, but not necessarily so. If no in- 
jury has been done to the spinal cord, it is possible to adjust the 
fractured bones by means of extension and counter-extension 
properly applied, and there they may be retained in position by 
a fixed apparatus, and recovery take place. 

It has been my fortune to treat three such cases successfully. 
The history of the two conditions, however, is so entirely differ- 
ent that, with proper care, they should not be confounded. 

The most common question you will be called upon to decide 
is, whether you have to deal with a deformity dependent upon 
paralysis, or one due to spastic contraction of muscles. 

This can be easily determined. If the deformity is of para- 
lytic origin, it can be readily overcome, and the head can be 
easily restored to its normal position ; but, the moment the 
retaining force is removed, the deformity will return. 

If, on the contrary, the deformity is the result of spastic con- 
traction, it cannot be so easily corrected. The rigidity of the 
muscle will be such as to render it impossible to restore the head 
to its proper position, unless the deformity is of very recent 
development. 

If it is of recent development the spastic contraction may per- 
haps be overcome by manipulation, and the head finally restored 
to its normal position. 

Such cases may be permanently relieved, perhaps, by means 
of elastic force so applied as to constantly make traction upon the 
head in a direction opposite to that in which it is inclined by the 
contracting muscle. 

When, however, the muscle has become contracture^ you 
will not be able to restore the head to its normal position by any 
manipulation, and when the parts are placed upon the stretch, and 
the additional point pressure made, spasm will be produced which 
indicates that the contracted tissues must be divided before the 
deformity can be overcome. 

When tenotomy is necessary, it is better to divide the clavicu- 
lar and sternal origins of the muscles separately than to make a 



451 



TREATMENT. 



single long incision embracing both of them from the same punct- 
ure. The clavicular origin can be reached most advantageously 
about three-fourths of an inch above the upper edge of the clavicle. 

The sternal origin of the muscle is more superficial than the 
clavicular, and can be reached more readily. There is some dif- 
ference of opinion among operators as to how the operation should 
be performed. Some prefer to cut the tendon from within out- 
ward, while others prefer to cut it from without inward. 

My preference is to cut from within outward, and I believe 
it to be a much safer method than to cut in the opposite direction. 
The tendons are to be divided in accordance with the rules already 
laid down, and when divided the head should at once be restored 
to its proper position and retained there. 

It is very important that every fibre of the muscle be divided, 
for, as long as a single fibre of the muscle remains undivided, the 
deformity cannot be permanently corrected. After the head has 
been restored to its normal position, it is to be retained by some 
apparatus. 

Here, again, we find that a number of instruments have been 




Fig. 269. 



devised for overcoming the deformity, but the greater portion of 
them are entirely unnecessary. 

Perhaps, the most simple and efficient apparatus is one that 
can be made of adhesive plaster and elastic bands. It is made in 
the following manner: First, place a broad piece of adhesive 



TORTICOLLIS. 455 

plaster across the forehead, to keep jour bandage from slipping. 
To each extremity of this piece of plaster a strip of muslin is at- 
tached, which goes around the head and is fastened. To this 
bandage, passing around the head, an elastic band is attached 
upon the side opposite the deformity, carried through the axilla, 
and returned to the place of beginning. JSow, this elastic band 
can be made as short as necessary to retain the head in its normal 
position, and it keeps a constant traction in the proper direction 
to turn the head around to its normal position. (See Fig. 269.) 

In this case it will be observed that the head is not yet entirely 
restored to the natural position ; but the constant traction will 
in time accomplish this object. The change in the position of the 
child's head, by the application of this elastic force, even during 
the few minutes it has been used, must be apparent to you all. 

This apparatus is very efficient for overcoming the deformity 
in the paralytic variety, or in any case when it can be overcome 
without the operation of tenotomy. 

The principle which should govern you in the treatment of 
this class of cases is, to supply the deficiency in muscular power 
by substituting elastic force. 

Nearly all the complicated machinery, therefore, which may 
be seen in the shops for correcting wry-neck, is of no use what- 
ever. 

If, however, it is desirable to furnish your patient with a 
beautiful instrument, you can probably do no better than to use 
the one devised by Mr. Reynders. {See Fig. 270.) 

This apparatus consists of a well-padded pelvic band, a, to 
which an upright steel bar is attached at I, passing upward along 
the spine to the upper dorsal region. A cross-bar, c, is attached 
to its upper end, passing from one axilla to the other, and fastened 
to two crutches, k, fitting well under the arm. These are con- 
nected to the pelvic band by two lateral bars, m, which by means 
of a slot and screw can be raised and lowered somewhat, at will. 
The part of the apparatus so far described is applied firmly to the 
trunk by means of straps passing over the shoulder and fastened 
to the axillary cross-bar at c c. A firm hold of the head is secured 
by a pad, sheet-steel inside, reaching almost from eye to eye back- 
ward around the skull, with apertures for the ears, and fastened to 
the head by straps over the forehead and under the chin. To its 
back part a steel bar is riveted, d, which connects the upper part 



456 



TKEATMEOT. 



of the apparatus with that applied to the trunk. The lower end 
of this steel bar is ratched and adjusted in a slide at the upper 
end of the steel rod, passing up along the spine and held in a 
desired position by a thumb-screw shown near the letter h (on the 
figure). This connecting bar is intercepted by three different 
joints, e,f, and g, by which flexion can be made in any direction, 
when worked with the key. At the joint g, flexion can be made 
to the right or left, at f forward and backward, and at e rotation. 




Fig. 270. 



The advantage of this apparatus over many others is, that 
firstly a firm hold is effected to the head and trunk, and that then 
the head can be brought in a proper position by a true and irre- 
sistible mechanism. The apparatus when worn is almost entirely 
hidden under the clothing, and patients cannot very easily with- 
draw themselves from its action. 

When the deformity is associated with disease of the cervical 
vertebrge, as it may be, you will require something more in the 
way of apparatus than the elastic band and the adhesive plaster. 



DISEASE OF THE WKIST-JOINT. 457 

In sncli cases the instrument just described answers a most 
excellent purpose. 

Another instrument which is less expensive, and is also very 
serviceable, consists of a saddle which fits the shoulders accurately, 
and is secured by means of a body-belt, with an arch over the 
head from the centre of which is suspended an elastic band to 
receive the occiput and chin. This apparatus was fully described 
when we were speaking of caries of the cervical vertebrae. 

As adjuvants to any apparatus that may be used, manipula- 
tion, friction, and galvanism, will be of great service. 

As soon as the sterno-cleido-mastoid muscles can act suffi- 
ciently to overcome the deformity without assistance, all appara- 
tus may be removed, but until that time it is important to assist 
them by means of elastic force. 

Disease of the Wrist-Joint. — I will next direct your atten- 
tion to a few points suggested by the case of disease at the wrist- 
joint which is now before us. 

This joint is liable to be attacked with the same diseases as 
other joints, and, when it becomes diseased, should be treated in 
accordance with the same principles that govern the treatment of 
other diseased joints. 

The following case is offered as an illustration not only of dis- 
ease but of the manner in which extension and counter-extension 
may be applied to the wrist-joint. 

Some time since this man received a fracture of the forearm. 
Phlegmonous erysipelas was developed in the limb, and thirteen 
openings were made to permit the free discharge of pus and 
serum. 

The hand and forearm were (Edematous, and pus was burrowing 
about in several places. The wrist-joint became involved in the 
inflammation, and the question of amputation was seriously con- 
sidered. Constitutional disturbance had become well marked. 

It was, however, decided to make an effort to save the limb, 
and the treatment consisted in keeping the openings free for dis- 
charge of such material as might be formed, the administration of 
such constitutional remedies as his case seemed to demand, such as 
iron, tonics, etc., and the application of extension and counter- 
extension in the following manner to relieve the constant pain in 
the joint. In the first place, each finger was bandaged separately. 
I then took a piece of common sole-leather long enough to reach 



458 WKIST-DKOP. 

from the upper portion of the forearm to the end of the fin- 
gers, and about as wide as half the circumference of the limb, 
dipped it in cold water until it was soft and flexible, and then 
moulded one end of it to the palm of the hand, and secured it with 
a roller-bandage ; then, as an assistant made extension from the 
hand and another from the elbow, until the surfaces of the dis- 
eased joint were separated and the pain relieved, I brought the 
remaining portion of the leather splint against the forearm and 
there secured it by continuing the roller-bandage up over the fore- 
arm. The splint was now left in position until it became dry, 
when it was removed and lined with a strip of adhesive plaster, 
plaster side out, of the same width as the splint and long enough 
to go completely around it lengthwise, and lap a couple of inches 
or more. It was then ready to be reapplied to the limb, and, 
after the openings had been covered with little pieces of oakum 
to absorb whatever discharge might take place, it was adjusted in 
the manner already described, first securing it to the hand, then 
making extension of the wrist and bringing the plaster against the 
forearm, and retained there by continuing the bandage over it. 

Sole-leather applied in this manner is stiff and unyielding when 
it becomes dry, and, if afterward it is covered with adhesive plas- 
ter, it will keep up perfect extension and counter-extension, there- 
by relieving the surfaces of the joint from all pressure. 

Inflammation of the wrist-joint is not very infrequent, and it 
is hardly possible to advise a simpler and more effective method 
for placing the joint perfectly at rest than that which you have 
just seen in operation in this case. 

Since the application of this splint, only one week ago, the 
cedematous condition then present has nearly disappeared; the 
discharge has diminished to a very great extent, the constitutional 
disturbance has passed away, and the question of amputation is no 
longer to be considered. 

Wrist-Drop. — The last deformity to which I shall direct your 
attention is that commonly known by the name of 

Wrist-drop. — This deformity consists, as its name implies, in 
a dropping of the hand, which is an undue flexion, consequent 
upon paralysis of the extensor muscles of the forearm. The most 
common cause of paralysis of the extensors of the forearm is 
lead-poisoning. 

When the " lead-palsy," as it is sometimes called, has con- 



WRIST-DROP.— " LAIRD'S BLOOM OF YOUTH." 459 

tinued for some time, atrophy of the muscles is a common result, 
and in many cases it is very marked. 

The opinion is quite common that the lead manifests its poi- 
sonous effects alone upon these extensor muscles, but that is not 
true. 

The lead affects the entire system, and the patient has not 
only wrist-drop, but he has diminished muscular power in all the 
muscles of the body. 

The poisonous effects are manifest in constipation consequent 
upon paralysis of the muscular coat of the intestine; and also 
give rise to a peculiar gait in which the patient first strikes the 
heel, and then brings his weight upon the anterior portion of the 
foot with a whack. The presence of the blue line along the mar- 
gin of the gums and the existence of lead in the urine are addi- 
tional evidences that the entire system is affected. 

The more common manifestation, however, of lead-poisoning 
is paralysis of the extensor muscles of the hand and fingers. The 
reason for this is, the flexor muscles are the more powerful of the 
two sets, and resist the influence of the lead longer than the ex- 
tensors, hence continue to act and produce the deformity after 
the extensors have become paralyzed. 

Those muscles exhibit the effect of the poison first which are 
the least able to resist its influence. 

In some cases paralysis of the extensors is complete, and the 
patient. is unable in the least degree to extend the hand and fin- 
gers. 

This deformity, incompletely developed, can be seen every day 
upon the streets of this city, for there is many a fashionable lady 
who suffers from it in consequence of her own folly. Their 
hands are held in a peculiar yet fashionable position, a sort of 
kangaroo style, and many of them fancy that they are imitating 
the fashion admirably, while they are simply obliged to carry 
their hands in this position because the extensor muscles are not 
strong enough to hold them up. The polish they have put on 
their faces has manifested itself in producing partial paralysis of 
the extensor muscles of the forearm, and a fashion has been intro- 
duced to accommodate the deformity. 

The use of " Laird's Bloom of Youth," as a cosmetic, is a very 
fruitful source of lead-poisoning among women. 

I have had three most distressing cases of this character under 



460 WKIST-DROP.— CASE. 

my own observation, which were caused by the use of this single 
article ; and yet the manufacturer has dared to use my name upon 
his advertisements, recommending it as a safe and reliable cos- 
metic ! 

The common people, perhaps, are not to blame for their igno- 
rance regarding these articles, but for the medical man there is 
no excuse for recommending such villainous compounds. 

General lead-poisoning is sometimes mistaken for locomotor 
ataxy. 

The following cases illustrate the deformity present in wrist- 
drop, and the mode of treatment : 

Case. — On the 27th of September, 1868, I was called to see 

Miss , of Kansas, who had been sent to me from that State, 

by Dr. Logan, to be treated for disease of the spine, and paralysis 
of the forearms. 

I found a very tall, beautiful woman of about nineteen, of 
remarkably large frame, very erect, with both hands dropped at 
nearly a right angle at the wrists, and perfect inability to extend 
them. She could not extend the fingers in the least, or extend or 
abduct either thumb. The muscles were more atrophied, and the 
forearms and hands more wasted than any case I had at that time 
ever seen. 

The largest circumference of the forearm just below the elbow 
was eight inches, circumference at wrist five inches. The inter- 
osseous spaces on the back of the hand were very distinct, and 
the adducens, and extensors of the thumbs, as well as all the 
muscles in the palms of the hands, were so atrophied that the 
contours of the first metacarpal bones on either side were almost 
as conspicuous as they would have been in a skeleton, with a tight 
glove drawn over it. 

She was unable to feed herself, comb her hair, pick up a pin, 
hook or button her dress, or in fact make any movements what- 
ever with her hands, except the very slightest flexion of her fin- 
gers. She had been in this condition for some months, and was 
gradually getting worse. She could flex and extend the forearms, 
and could elevate the arms almost to a right angle with the body ; 
but was perfectly unable to extend the hands or fingers in the 
least. She could walk tolerably well, but was not very steady or 
elastic in her step, and easily became exhausted. Going up or 
down stairs was done with great difficulty, and I observed that, 



CASE. 461 

to sit down, or get up from a very low seat, required all the mus- 
cular exertion of which she was capable. 

On removing her clothes to examine the spine, I found that 
she was sustained in the very erect position, which had attracted 
my attention, by " Taylor's Spinal Supporter," a most valuable 
apparatus in cases where its use is indicated, and I naturally in- 
ferred that she must have been suffering from some disease of 
the spine. On removing the supporter, which weighed three 
pounds, her head and trunk immediately bent forward; and 
with her arms crossed on the chest, the hands dropped at the 
wrist, at almost an acute angle with the forearms, she presented 
an exact counterpart of the " Grecian-bend " photograph, which 
has been so common in the shop-windows for the past year or 
more. 

I examined her spinal column with the greatest possible care, 
by concussion, compression, extension, bending her forward, back- 
ward, laterally, and by rotating the spine upon the pelvis, so as 
to put every ligament upon extreme tension, and subject every 
cartilage and bone to finn pressure, without the slightest evi- 
dence of pain or inconvenience. I therefore concluded that, if 
she had ever had Pott's disease of the spine, it was the most per- 
fect cure that I had ever seen. 

She gave the following history of herself : That in the sum- 
mer of 1866 she had bilious intermittent fever for some weeks, 
which prostrated her very much, and after slight fatigue she had 
a relapse from which she recovered very slowly. That in Sep- 
tember she took a ride on horseback, a distance of ten miles, and 
on her return the horse ran off, and carried her at great speed 
nearly a mile. She exerted all her strength to stop him without 
effect, and was finally compelled to put him into a fence. She 
was very much exhausted, but did not dismount until she reached 
home, a distance of some two miles or more. A few days after 
this great exertion, she found " her hands were getting weak, 
first discovered it by accidentally dropping a skillet out of her 
hands at a candy-pulling." She then noticed that a book would 
frequently drop out of her hands while reading, and that she 
could not strike the piano-keys correctly, or with as much force 
as formerly, and that her arms and hands were getting much 
thinner. 

She came to New York to consult me ; but, as I was absent 



462 WRIST-DROP. 

from the city, she was recommended to Dr. C. F. Taylor, to try 
the Swedish movement-cure. The doctor diagnosticated her 
case as Pott's disease, and applied a spinal supporter. She was 
very ill for some days at Dr. Taylor's establishment in Broadway, 
with what the doctor states in his letter to Dr. Logan, of Leaven- 
worth, was spinal osteitis. Dr. Thomas, who saw her at this time 
in consultation, informs me that he considered her case as one of 
hysteria. 

She was sent home after a few weeks, with the spinal sup- 
porter applied, and which she has continued to wear until the 
present time, having been assured that her hands and arms 
would soon recover their use, after her back got well. I mention 
these facts, not in the way of censure, but simply to show the 
difficulty of diagnosis, and the danger of drawing wrong conclu- 
sions, without the most careful observation, for this very case was 
published in the Quarterly Journal of Physiological Medicine, 
April, 1868, pp. 282, 283, as a case of " carnomaniaP 

Her back seemed to be supported by the brace, and she could 
walk with her body more erect ; but her entire muscular system 
grew weaker, she could walk only a short distance without great 
fatigue, and her forearms and hands wasted so rapidly that in a 
few months she completely lost the power of extension, and for 
the past year had been perfectly helpless, and had to be dressed 
and fed like a child. 

As I could find no evidence of disease in the spinal column, 
or cord, and no organic lesion of the nervous centres, my diagno- 
sis was that there was no "Pott's disease," but a case of " lead- 
palsy." The usual blue margin of the gum was not conspicuous, 
but between each of the teeth the gum was more purple than 
natural. 

I made most careful inquiry to ascertain the source of the 
lead, but was not successful. They had no lead pipes in the 
house to contaminate the water drank, but took it from a spring 
in wooden buckets, had used no lead in painting the house, had 
drunk nothing from lead pipes, or been exposed to its influence 
in any way that I could ascertain, even after the most careful 
inquiry. 

Prof. William A. Hammond saw her in consultation on the 
following day, and, without my giving him any hint or informa- 
tion, confirmed my diagnosis of lead-palsy, although from the 



PAEALYSIS FROM ''LAIRD'S BLOOM OF YOUTH.' 1 463 

mother's description lie expected to find a case of " Pott's dis- 
ease," and examined her especially for it. 

Not being able to ascertain, after the most careful inquiry, 
any source from which the lead could have been received into the 
system, he stated that it might possibly be a case of muscular 
atrophy from excessive use, and, unless the muscles could be 
stimulated by the continuous current of galvanism, the prognosis 
was very unfavorable. 

The exertion of stopping the runaway horse seemed to justify 
this opinion. I applied a powerful battery of Kidder's without 
producing any muscular contraction. 

As there was rather profuse menstruation, attended with 
great pain, and intense vaginismus, and as Dr. Thomas had in- 
formed me that there was an hysterical element in the case when 
he had seen her two years before, I called Dr. Marion Sims in 
consultation September 27, 1868. 

The pain of examination was so intense that, having no chlo- 
roform at hand, we had to postpone it. 

September 28th, Dr. Sims and Dr. Neftel saw her with me, 
and I had to carry the chloroform to profoimd stupor, with ster- 
torous respiration, before Dr. Sims could make any examination 
of the vagina. ~No serious disease was discovered save this intense 
vaginismus. Dr. Neftel stated that he had seen three cases of 
" lead-palsy " in which vaginismus had been a prominent symp- 
tom. Is it a symptom of the disease in females ? 

On again examining her for the source of the lead, she asked 
me " if it could possibly come from the whiting." On asking her 
what that was, she informed me that it was the " Bloom of Youth," 
used for the complexion, and manufactured by Laird, 74 Fulton 
Street, Eew York. She had used nearly a bottle a month, for 
about two years and a half, but for the last eight or nine months 
had been compelled to have the application made by an assistant, 
as she was unable to apply it herself. 

She gave me the remnants of a bottle of the " Bloom of 
Youth," which, upon analysis by Prof. P. O. Doremus, was 
found to be highly impregnated with acetate and carbonate of 
lead. 

I immediately put her on large doses of iodide of potassium, 
commencing with twenty grains a day, and increased it up to 
ninety. Collecting the secretion of urine for the following three 



464 WEIST-DROP. 

days, I also sent it to the doctor for examination, and received 
the following reply : 

" New York, October 8, 1868. 
" My deae Doctoe : The sample of urine you sent me yields a small quan- 
tity of lead. Yours cordially, 

"B. OODEN DoEEMUS. 
" Prof. Sayre." 

After she had been under the use of the iodide of potassium 
for about one week, the Kidder's battery, at the same strength as 
at first applied without effect, now produced quite vigorous con- 
tractions. 

Its use was now continued every other day, for about ten or 
twenty minutes at a time, with most marked improvement. 

Believing that the natural position of the fingers was impor- 
tant to sustain the circulation, and that voluntary exercise was 
necessary to increase the nutrition and development of the mus- 
cles, I got Dr. Hudson, the manufacturer of artificial limbs, to 
construct for her a very light extension apparatus for the hands 
and fingers, which answered the purpose most admirably. 

Dr. Hudson has made another set of these instruments for me 
in another case, which are so great an improvement upon the first 
that I will refer to them in the description of the case in which 
they were applied. 

With the instruments properly adjusted she could play upon 
the piano remarkably well, and I think that this use of her hands 
materially aided in expediting her recovery, which is now almost 
perfectly complete. 

I received a letter from her dated November 25, 1868, written 
in a most beautiful hand, and in which she states : " My hands 
have improved wonderfully, and beyond all expectation. . . . My 
left hand, which, you will remember, I could only raise for a 
second, and then with great difficulty, I can now use better than 
I could my right hand when you saw me two weeks ago. My 
right hand has improved so rapidly that I can extend the fingers 
almost perfectly straight. ... I have gained over twenty pounds, 
and my arms measure at the wrist six and a quarter inches, and 
just below the elbow nine and a half. And I feel better in every 
particular than I have for more than two years." 

Case. — Mrs. , residing on the Hudson Kiver, came to 

me, November, 1868, suffering from complete paralysis of the 



CASE. 465 

extensor muscles of both hands, and of all the fingers, caused by 
the use of " Laird's Bloom of Youth." The arms were cold, the 
interosseous muscles were wasted, as well as all those upon the 
posterior aspect of the forearms. 

The paralyzed muscles give no response to a current from a 
strong Kidder's battery. The arms measured above the wrists 
five inches, below the elbows seven and a half inches. 

Three years ago she commenced using "Laird's Bloom of 
Youth," for the complexion. After a year she began to suffer 
from nausea, pain in the back, colic-like pains, frequent headaches, 
with general debility. Shortly after this she began to observe 
weariness in the extensor muscles of the wrists and forearms, both 
hands having a tendency to drop. 

Drs. Clark and Thomas, of this city, saw her in consultation 
with her regular attending physician, Dr. Hasbrouck ; by them the 
case was considered (as the patient states) as one of " paralysis and 
nervous debility, with dyspepsia." 

She continued to use the cosmetic at the rate of about a bottle 
a month. 

The paralysis of the extensors increased continuously, until for 
the last six months she has become perfectly helpless as regards 
the power of extension of the hands or fingers. She has to be fed 
and dressed by her maid ; in fact, has no more use of the hands 
than if they were dead. 

She walks with an inelastic step, stumbles on going up and 
down stairs, and becomes easily exhausted upon any muscular 
exertion. In this case there was slight blueness on the margin of 
the gums. 

I gave her 90 grains of iodide of potassium every day, with 
dilute sulphuric acid, and ordered a " Turkish bath " twice a week. 
At the end of one week the battery, applied with the same power, 
produced manifest contractions. This was applied every other 
day for twenty or thirty minutes, friction and shampooing of the 
muscles, with passive movements every day, and in three months 
she had so far recovered as to dress herself — even to the putting 
on of a well-fitting glove, and also buttoning it. At the end of 
five months she had entirely recovered, and gained twenty-eight 
pounds in weight. 

Case. — Miss , of Maryland, aged twenty-one, came to me 

in April, 1869, with complete loss of power of all the extensor 
30 



466 WRIST-DROP. 

muscles of both forearms. The hands were wasted to a skeleton, 
and the interosseous spaces on the back of the forearm of either 
side were so conspicuous and deep that, when her forearms were 
prone and flexed at a right angle with the arms, water would re- 
main in them like a trough. (See Figs. 271 and 272.) 

She stated that five years before, in 1864, while very thinly 
clad, she was exposed to intense cold; that both of her arms 
were nearly frozen, and looked almost transparent. This expos- 
ure was followed by a rheumatic fever, confining her to bed for 
three months. During this attack, and after her recovery, she 
was troubled with severe constipation, frequent attacks of colic, 
and constant nausea. Was compelled several times to resort to 
croton-oil to secure an action from the bowels. 

In 1865 she went to Canada to be under the charge of Dr. 
Mack, who treated her for some uterine trouble (was it vaginis- 
mus ?), and also applied the actual cautery to the lower part of the 
spine, but all without any benefit, as the colic, cramps in the 
stomach, nausea, and general prostration, remained the same as 
before. 

In 1866 she first began to notice the dropping of her hands 
and the wasting of her forearms. About this time she made a 
violent exertion in attempting to hold a hard-pulling pair of 
horses in their attempt to run away with her, and immediately 
after lost all power over both of her hands. The flexor muscles 
after a while recovered slightly, but the extensors of the fingers 
and hand have remained powerless until the present time. 

Dr. S. Weir Mitchell, of Philadelphia, has treated her for the 
last two winters with electricity, but so far as extension of the 
hands or fingers is concerned without the slighest apparent bene- 
fit. 

She states that the muscles of her arms and shoulders have 
very materially improved under Dr. Mitchell's treatment, and 
that her general health is somewhat better, but that her hands and 
fingers are the same as at first, and that Dr. M. had given her a 
very unfavorable prognosis. 

Dr. Mitchell's knowledge, skill, and experience in the use of 
electricity being equal, if not superior, to those of any one in this 
country, I felt satisfied that she had had all the benefit that that 
agent alone could give her, and I asked her if he had ever sus- 
pected that lead had anything to do as an agent in causing the 



CASE. 



467 



paralysis. She replied that he had not ; but that she had recently 
informed him of my first case, which was so similar to her own 
as to attract her attention, and stated to him that she had used 
the same material, " Laird's Bloom of Youth," since she was six- 
teen years of age. He then gave her iodide of potassium, but as 
there was no improvement he was inclined to think that lead had 
nothing to do with it. 

My impression is, judging from the result since, that he did 
not give the medicine in sufficient quantity. 

I applied the electrodes from a seventy-cell Kidder's battery, 
and also from a powerful battery of Drescher's without producing 
the slightest contraction of any of the extensor muscles except a 
very feeble action in the extensor minimi digiti and a barely per- 
ceptible action in the extensors of the ring-fingers. Sensation 
was not entirely abolished. The same battery with only thirty 
cells when applied to the shoulders or lower extremities produced 




Fig. 271. 



strong muscular contractions. I immediately put her on 90 grains 
of iodide of potassium a day, and, as soon as the specific eruption 
of this medicine began to appear upon the face and neck, the same 
battery would produce manifest contractions. 

The electricity (continuous current) was applied about fifteen 



468 



WRIST-DROP. 



minutes every day, and she wore Dr. Hudson's extension appa- 
ratus most of the time, day and night. At the end of three 
weeks, without the extension apparatus, she was able to take a 





Fig. 272. 



plate of ice-cream in her left hand, and feed herself with a spoon 
in the right, a thing she had not done for two years. 

Of the value of Dr. Hudson's apparatus in cases of this kind, 
I cannot speak in too high terms. It is very light and beautiful, 




Fig. 273. 



is worn without any inconvenience, enables the patient to exer- 
cise the muscles of the hands and fingers constantly, and thus 
materially facilitates nutrition and development. Figs. 273 and 



CASE. 



469 



274 give a very good idea of its construction and manner of 
application. 

Fig. 272 is a cnt from plaster-casts of her arms, taken for Dr. 
H., to adjust the extension instruments by. 

Figs. 271 and 274 show the difference in the position of her 
hands, before and after instruments were applied. 

All of these cuts are from photographs by Mr. Mason, pho- 
tographer to Bellevue Hospital. 

This patient recovered entirely in about eighteen months from 




Fig. 274. 



the time the treatment was commenced, although the case at first 
was considered as almost hopeless. 

The use of cosmetics has within a few years become so very 
common, even among the better classes of society, and, as most, 
if not all of them, are equally as dangerous to use as the particu- 
lar one described in this report, I have deemed it my duty to 
place these cases before the profession, that, knowing their in- 
jurious effects, they can guard their patients against thus volun- 
tarily poisoning themselves through ignorance. 

This class of cases has, also, been mistaken for spinal conges- 
tion, and the patients have had their backs burnt with moxas. 
In females there is almost always associated, with wrist-drop from 
lead-poisoning, a condition which has been called vaginismus. 
This is an irritable condition of the vagina that may very easily 
lead to errors in diagnosis, unless proper care is exercised in the 
examination of the case. This condition of the vagina has been 
particularly described by Dr. J. Marion Sims, of this city. 



470 WKIST-DROR— TREATMENT. 

In all doubtful cases a careful analysis of the urine should be 
made, for, if lead is present in the system, it can be very easily 
detected in this excretion. 

Treatment. — The indications in the treatment are to elimi- 
nate the poison from the system ; to restore lost or impaired 
muscular power, and to assist the muscles in the performance of 
their functions. 

Recovery is usually complete when these indications are prop- 
erly fulfilled. 

For eliminating the poison, iodide of potassium is the chief 
remedy ; and it must be administered in such quantities as will 
increase the elimination, which is gradually taking place through 
the kidneys. 

In many cases success has not been obtained in this direction, 
simply because the remedy has not been used in sufficient quan- 
tities. 

It may be administered, if necessary, at the rate of 120 or 150 
grains a day, although 60 or 80 is all that is usually required. 

The means to be used for restoring lost or impaired muscular 
power, in addition to the internal treatment, are galvanism, hypo- 
dermic injections of strychnine, friction, etc. These measures 
must not be employed, however, in such a manner as to produce 
over-fatigue of the muscles. Galvanism should be used only 
when the muscles are properly supported, so that they will not 
be obliged to lift any weight when stimulated to contract. 

To afford mechanical support to the muscles, a very convenient 
apparatus can be constructed of adhesive plaster and elastic bands, 
as suggested by Dr. Yan Bibber, of Baltimore. Attach two strips 
of adhesive plaster to the posterior surface of the forearm in the 
form of a letter V? with the apex of the letter toward the elbow. 
The lower extremities of these strips will serve as points for the 
attachment of pieces of elastic bands or rubber artificial muscles. 
A piece of fine elastic bandage, attached to one extremity of a 
strip of plaster, may be passed into the palm of the hand around 
the middle and ring fingers, and back to the extremity of the 
other piece of plaster. This furnishes a constant elastic force, 
which gives support to the paralyzed muscles, and does not inter- 
rupt or impede motion, but is not to be compared, in practical 
utility, with the ingenious device of Dr. Hudson, as seen in Figs. 
273 and 274. 



REMARKS. 471 

And now, gentlemen, having come to the end of the term, 
where our lectures must close, I would assure you that no one 
regrets more than myself that want of time prevented me from 
making them more thorough and complete. I have endeavored, 
in the short space of time allotted to me, to explain to you, as 
clearly as possible, my views in regard to the pathology of the 
diseases and deformities referred to, and the general principles 
of their treatment, giving you practical illustrations of the ap- 
plication of these principles in the different cases that have been 
brought before you. 

You may find in your future practice some cases which you 
may not have had an opportunity of clinically examining during 
this course of lectures ; but the same general principles which I 
have demonstrated to you in the cases which have been presented, 
I think you will find equally applicable to them. You must de- 
pend upon your own ingenuity and observation for the practical 
application of them. 

Many of the doctrines I have taught, you will find in direct 
variance with those of your text-books, and you may meet with 
opposition from your professional brethren when you come to 
put them in practice. Having tested them so frequently myself, 
I feel confidence in commending them to you as being reliable. 
If in practice you find that they will not bear the test of experi- 
ence, you are at liberty to reject them. If in the future you can 
discover new methods which are more satisfactory, it will be your 
duty to adopt them, as I would myself- renounce any doctrine 
that I had ever taught whenever I was convinced of its error, 
and adopt other methods of treatment which my judgment pro- 
nounced superior to what I had practised before. Thanking you 
for your devoted attention during my lectures, and wishing you 
a happy, useful, and prosperous professional career, I bid you all 
God speed, and an affectionate farewell. 



INDEX 



A. 



Abscess, inguinal, 343 

Adhesive plaster, proper application of, 
33 ; use of, in maintaining traction, 33. 

Air, danger of admitting it to synovial 
cavities, 197. 

Anaesthetics, use of, in orthopedic opera- 
tions, 30. 

Anchylosis as a result of non-use of joints, 
12 ; best position of limb in, 211 ; 
bony, or true, 423 ; case of cure of, 
256 ; description and varieties of, 399 ; 
treatment of, by brisement force, 404 ; 
of both hip-joints, case of, 424 ; or 
knee, case of, 408 ; of knee, fibrous, 
cases of, 410, 413, 414 ; of hip, fibrous, 
case of, 417 ; of hip, case of, 415 ; of 
hip, from rheumatic inflammation, 
case of, 418; of hip-joint, post-mortem 
examination of case of, 440 ; of left 
hip-joint, case of, 429. 

Andry, Prof., of Paris, the founder of or- 
thopedy, 3. 

Angular curvature, or Pott's disease, 360. 

Ankle-joint, apparatus for treatment of, 
163; case of caries of, 178; cases of 
disease of, 166-168, 171 ; differential 
diagnosis of diseases of, 156 ; diseases 
of, 153 ; suppuration and caries of 
both, etc., cure, case of, 172 ; suppu- 
ration and caries of, operation, cure, 
case of, 176. 

Arteries, pressure on, as a means of pre- 
venting inflammation, 21 6. 

Atlee, on the treatment oi talipes, 92. 



B. 



Barwell's apparatus for lateral curvature, 
392. 

Baths, therapeutic value of, 44. 

Bed-extension in hip -joint disease, 267. 

Bigelow, Dr. Henry J., dissertation of, on 
orthopedic surgery, 6. 

" Bloom of Youth "as a cause of " wrist- 
drop," 13. 

Bunions and corns, 138. 

Bunions, treatment of, 140. 

Brodie, Sir Benjamin, on disease of the 
knee-joint, 199. 



Bursitis of knee-joint, 224. 
Bursitis, treatment of, 225. 
Bums, talipes calcaneus caused by, 53 
Bush, Dr. J. M., letter from, to Dr. Sayre, 
445. 



C. 



Caries of the ankle-joint, case of, 178 ; of 
ilium, case of, 335 ; of the ilium, 334 ; 
of ischium, case of, 338 ; of ischium, 
337. 

Celsus on the cure of deformities, 2. 

Chorea induced by anxiety on account of 
deformity, 22. 

Circumcision, performance of, 15. 

Clinical study, importance of, S. 

Club-foot, varieties of (see Talipes), 47. 

Contractions, reflex muscular, caused by 
phimosis, 13. 

Corns, cause and treatment of, 139. 

Cosmetics as a cause of deformities, 13 ; 
danger of use of, 469. 

Cosmoline, use of, 45. 

Crosbv, Prof. A. B., cheap shoes for club- 
foot, 91. 

Crutch, wheel, Darrach & Co.'s, 273. 



D. 



Darrach' s apparatus for support, 209. 

Darrach & Co., wheel-crutch of, 273. 

Davis, Dr. H. G., apparatus of, for hip- 
joint disease, 260. 

Davis's instrument for Pott's disease, 371. 

Deformities, acquired, 11 ; varieties and 
classification of, 9; various, unclassi- 
fied, 450. 

Detmold's apparatus for facial paralysis, 
451. 

Detmold, Dr. William, an advocate of 
tenotomy, 4, 95. 

Diastasis of head of femur simulating hip- 
disease, 350. 

Diet and fresh air, importance of, in de- 
formities, 45. 

Dislocation of femur, differential diagno- 
sis of, from hip-disease, 349. 

Displacement of pelvic bones, congenital, 
343. 



474 



INDEX. 



Doyle, Dr. Gregory, letter from, to Dr. 
Sayre, 443. 

Dry heat, value of, in paralytic deformi- 
ties, 43. 



E. 



Elastic force, application arid use of, 129 ; 
pressure, mode of applying to the 
ankle-joint, 161 ; tension, 32. 

Elbow-joint, anchylosis of, 447 ; case of 
anchylosis of, 447. 

Electricity, cases treated by, 36 ; rules for 
the use of, in paralysis, 35. 

Equino- varus, 51. 

Etiology of deformities, 11. 

Exsection of head of femur, first success- 
ful case of, in America, 295 ; of head 
of femur, Sayre's, fifty-nine cases of, 
314; of hinge -joints, objections to, 
165 ; of hip-joint, cases of, 301, 305, 
306, 308, 310 ; of hip-joint, mode of 
performing, 287. 

Exsection of knee-joint, mode of perform- 
ing, 219 ; for relief of hip-joint dis- 
ease, history of, 285. 



F. 



Facial paralysis, deformity accompanying, 
450. 

Fatty degeneration of muscle, diagnosis of, 
36. 

Femur, diastasis of head of, simulating 
hip-disease, 350 ; diastasis of head of, 
cases of, 350, 352, 353 ; exsection of 
head of, first successful case in Amer- 
ica, 295 ; necrosis of lower extremity 
of, 225 ; periostitis of, 339. 

Flint, Prof. A., Jr., letter from, to Dr. 
Sayre, 445. 

Foot, the human, bones and articulations 
of, 48/ 



Galvanism and faradism, use of. in pro- 
moting muscular growth, 35, 87, 100, 
101. 

Genital excitement as a cause of paralysis, 
17. 

Genu-valgum, apparatus for treatment of, 
149 ; case of, illustrated, 150 ; or knock- 
knee, 148. 

Gymnastics, use of. in the treatment of de- 
formities, 45. 



II, 



History of orthopedy, 3. 

Head of femur, Sayre's fifty-nine cases of, 
314. 

Heat, drv, value of, in paralytic deformi- 
ties, 43. 

Hip-disease, comparison of second and 
third stages of, 249. 

Hip, injuries of, 349. 



Hip-joint, anatomy of, 227. 

Hip-joint, diseases of, 227. 

Hip-joint disease, first stage of, 234 ; sec- 
ond stage of, 244 ; third stage of, 247 ; 
etiology of, 232 ; cases of, 245 ; synop- 
sis of cases of, 326 ; of eleven years' 
standing, case of, 280. 

Hip-joint, diagnosis ot diseases of, 234 ; 
cases of exsection of, 301, 305, 306, 308, 
310; exsection of, 254; post-mortem 
examination in case of, 253. 

Hippocrates on the treatment of club-foot, 
2. 



I. 



Ilium, caries of, 334 ; case of caries of, 335 ; 
case of removal of, 357. 

India-rubber, use of, in extension, 33. 

Inflammation, articular, as a cause of de- 
formity, 11. 

Ingrowing toe-nail, treatment of, 142. 

Inguinal abscess, 343. 

Injuries as a cause of deformities, 21 ; of 
the hip, 349. 

Instruments necessary for tenotomy and 
myotomy, 26. 

Inunction, why useful, 44. 

Iodine, best method of using locally, 196. 

Irritation, nervous, consequent on genital 
excitement, 17. 

Ischium, caries of, 337 ; caries of, case of, 



Joints, diseases of, 153. 

Joint, safety of opening, in disease, 160. 



K. 



Knee-joint, diseases of, 184 ; exsection of, 
mode of performing, 219 ; indications 
for exsection of, 223 ; instrument for 
making extension of, 202 ; operative 
interference in bony anchylosis of, 
446 ; treatment of diseases of, 193. 

Knee-joint disease mistaken for morbus 
coxarius, 333. 



L. 



" Laird's Bloom of Youth," lead-poisoning 

from, 459. 
Lateral curvature of spine, 386 ; case of, 

with illustration, 395 ; causes of, 387 ; 

symptoms of, 390 ; treatment of, 390. 
Lateral motion of the ankle-joint, opinion 

of author on, 48. 
Latissimus dorsi, section of, 397. 
Lead-palsy, cases of, 464, 465. 
Lead-poisoning, treatment of, 470. 
Lee, Dr. Benjamin, on a severe case of 

talipes, 98. 
Luxation in morbus coxarius, 254. 



IIS T DEX. 



475 



M. 



Manipulation, importance of, in deformi- 
ties, 41. 

March, Dr. Alden, on hip-joint disease, 
249. 

Massage in the treatment of deformities, 
43. 

Mechanical appliances in deformities, 42. 

Medicinal agents, comparative value of, 45. 

Mental influence of deformity, 22. 

Morbus coxarius, or hip-disease, 227 ; dif- 
ferential diagnosis of, from dislocation 
of femur, 349; treatment of, 257; 
treatment of first stage of, 273 ; treat- 
ment of second stage of, 275 ; treat- 
ment of third stage of, 278. 

Mott, Dr. Valentine, on orthopedic sur- 
gery, 5. 

N. 

Necrosis of lower end of femur, -with an- 
chylosis^ case of, 409. 

Neil's treatment for talipes, 92. 

Nelaton's test for congenital displacement 
of pelvic bones, 345. 

Nelaton's or Koser's test for fracture of 
head of femur, 350. 

Nelson's fracture-bed, 434. 



0. 



Oakum, value of, as a dressing, 167. 
Orthopedic apparatus, principal requisites 

of, 31. 
Orthopedy, definition of the word, as 

adopted, 7. 



P. 



Packard, Dr. John F., splint of, 220. 

Pain, importance of, in diagnosis of joint- 
diseases, 193. 

Paralysis as a cause of deformities, 12 ; fa- 
cial, deformity accompanying, 450 ; of 
lower extremities simulating hip-dis- 
ease, case of, 348. 

Paralytic equinus, with contraction of ten- 
do-Achillis, etc., case of, 136. 

Parker, Prof. Willard, letter from, to Dr. 
Sayre, 445. 

Pathology of hip-joint disease, 229. 

Pelvis, congenital malformations of, 343. 

Periostitis of trochanter, cases of, 339, 341. 

Phimosis and adherent prepuce, congenital, 
13. 

Poisoning, metallic, as a cause of deformi- 
ties, 13. 

Pott's disease, or angular curvature, 360; 
symptoms and diagnosis of, 363 ; plas- 
ter-of-Paris dressing for, 374 ; cases of, 
377, 378, 381-383 ; treatment of, 368. 

Pott's disease and psoas abscess, differen- 
tial diagnosis of, from morbus coxari- 
us, 342. 

Prepuce, adherent, 13 ; case of talipes due 
to, 16. 



Probe, Savre's flexible vertebrated, 224 ; 
Steele's elastic flexible, 224. 

Prognosis in cases of deformity, 21. 

Psoas magnus and iliacus muscles, inflam- 
mation of, 343. 

Puncturing the hip-joint, 277. 

Puncture of joints, directions for, 197. 



E. 



Keflex contractions of flexor and adductor 
muscles of left thigh, case of, 420. 

Keflex paralysis, typical case of, 18. 

Kest, long-cbntinued, as a cause of deformi- 
ties, 12, 

Kogers, Dr. David L., a pioneer in tenoto- 
my, 4. 

Kotary-lateral curvature of the spine, 386. 



Sacro-iliac disease, 327 ; case of, mistaken 
for hip-disease, 332 ; treatment of, 331. 

Savre's fiftv-nine cases of exsection of head 
of femur, 314. 

Scrofulous disease of the knee-joint, 191. 

Shoe, improved, for club-foot, Sayre's, 89 ; 
for double inversion, 133. 

Spine, deformities of, 386; diseases and 
deformities of, 360. 

Spiral corset for lateral curvature, 394. 

Splint for hip-joint disease, Sayre's, 262; 
long, for "disease of hip joint, 269. 

Strychnia as a remedy in paralysis, 46. 

Synovial fluid, removal of excessive, 197. 

Synovitis, acute and chronic, 186; of knee- 
joint, chronic, cases of, 211, 214, 217 ; 
of hip-joint, 229. 

Supernumerary toes and fingers, 143. 

Svme, opinion of, on hip-joint disease, 259, 
284. 



T. 



Talipes, apparatus for the treatment of, 
82 ; calcaneus, 52 ; calcaneo - valgus 
paralytica, case of, 106; causes of, 72; 
complications of, 76 ; equinus, 51 ; 
equinus, paralytic variety of, 51 ; equi- 
no-varus, congenital, case of, 103; 
equino- varus, double, case of, 16, 109 ; 
plantaris, case of, 114 ; plantaris, 72 ; 
plantaris, or cavus. traumatica, 116 ; 
Keynders's shoe for, 70 ; treatment 
of, by Dr. Henry Neil, 92 ; treatment 
of, 77; valgus, " double, case of, 66; 
valgus, cases of, 63, 65-67; valgus, 
causes and complications of, 61 ; val- 
gus, pathology and symptoms of, 62 ; 
varieties of, 47 ; varo-equinus, para- 
lytica, cases of, 58, 93 ; varus, double, 
acquired, case of, 122; varo-equinus, 
congenital, double, case of, 119 ; va- 
rus, double, case of, 102 ; varus, cases 
of, 126, 127 ; varus, congenital double, 
case of, 121 ; varus paralytica, acquired, 
case of, 118; varus, varieties of, 57 ; va- 
rus and varo-calcaneus, cases of, 108. 



476 



INDEX. 



Tarsometatarsal articulation, disease of, 
181 ; case of disease of, 183. 

Taylor, Dr. C. Fayette, brace for Pott's 
disease, 370. . 

Temperature, lowering of, in shortening 
limbs, 12. 

Tendons, displacement of, 144. 

Tendon, displaced, case of, 144. 

Tendo-Achillis, treatment of rupture of, 
54 ; case of division of, treated by Dr. 
Yale, 54. 

Tenotomy in talipes, origin and history of, 
95 ; when to perform, 27 ; in talipes, 
dressing after, 97 ; method of per- 
forming, 28. 

Tension, elastic, 32. 

Thermoscope, Dr. Seguin's, value of, 188. 

Toes and fingers, supernumerary, 143. 

Torticollis, or wry-neck, 451 ; treatment 
of, 453. 

Treatment of congenital deformities, im- 
portance of early, 25 ; of deformities, 
genera] principles of, 25. 

Trochanter, periostitis of, 339. 



Trochanter, cases of periostitis of, 
341. 



V. 

Vaginismus in lead-palsy, 463. 

Van Bibber, elastic bands of, 470. 

Varo-equinus, 51 ; case of double congeni- 
tal, 134 ; of left, and varo-calcaneus 
of right foot, case of, 131. 

Venery, excessive, as a cause of paralysis, 
15. 

W. 

Webber, Prof. E. W., experiments of, on 
hip-joint, 243. 

White-swelling, 191. 

Wrist-drop, 458 ; case of, 460. 

Wrist-joint, disease of, 457 ; case of dis- 
ease of, 457. 

Wyeth, Dr. J. A., on excision of hip- 
joint, 289. 



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dress the non-scientific public for purposes of exposition and explanation. 

The Popular Science Monthly is the organ of no sect, party, or school, but 
will be devoted to the broad interests of advancing knowledge, as it is expounded 
by the eminent thinkers of England, France, Germany, and the United States, each 
writer being responsible for his own views. 

OPINIONS OF THE PRESS. 

"Just the publication needed at the present day."— Montreal Gazette. 

"It is, beyond comparison, the best attempt at journalism of the kind ever made in this 
country.'"— Home Journal. 

"The initial number is admirably constituted/'— Evening Mail. 

" In our opinion, the right idea has been happily hit in the plan of this new monthly." 
Buffalo Courier. 

"A journal which promises to be of eminent value to the cause of popular education in 
this country."— iV. Y. Tribune. 

I3IPOBTANT TO CLUBS. 

The Popular Science Monthly will be supplied at reduced rates with any pe' 
riodical published in this country or Europe. 

Payment, in all cases, must be in advance. 

D. APPLETON & CO., 

549 & 551 Broadway, New York, 



MIND: 

Jl QUARTERLY SlLVTZJ-W 

OF 

PSYCHOLOGY AND PHILOSOPHY, 



EDITED BY 



GEORGE CROOM ROBERTSON, ffl. A,, 

Professor of PMlosophy of Mind and Logic in University College, London. 



MIND will be an organ for the publication of original researches, and a critical 
record of the progress made, in Psychology and Philosophy. 

Psychology, while drawing its fundamental data from subjective consciousness, 
will be understood in the widest sense, as covering all related lines of objective 
inquiry. Due prominence will be given to the physiological investigation of Nerve- 
structures. At the same time. Language and all other natural expressions or prod- 
ucts of mind, Insanity and all other abnormal mental phases, the Manners and 
Customs of Races as evincing their mental nature, mind as exhibited in Animals 
generally — much of what is meant by Anthropology, and all that is meant by Com- 
parative Psychology — will come within the scope of the Eeview. 

The practical application of psychological theory to Education will receive the 
attention it so urgently claims at the present time. 

Beyond Psychology, account will be taken of Logic, ^Esthetics, and Ethics, the 
theory of mental functions being naturally followed by the doctrine of their regula- 
tion. 

For the rest, MIND will be occupied with general Philosophy. Even as a scien- 
tific journal, it cannot evade ultimate questions of the philosophical order, suggested 
as these are with peculiar directness by psychological inquiry. There is, also, a 
function truly philosophical which only the investigator of mind is in a position to 
discharge, the task, namely, of collating and sifting the results of the special sci- 
ences with a view alike to insight and conduct. But MIND will, further, expressly 
seek to foster thought of bold sweep — sweep that can never be too bold, so be that 
it starts from a well-ascertained ground of experience, and looks to come again there 
to rest. 

Nor, in this connection, will the History of Philosophy be overlooked ; whether 
as it involves the critical appreciation of the systems of thought more or less specu- 
lative, which eager minds in every age have been impelled to frame ; or as it seeks 
to understand important thinkers in the record of their lives : or, finally, as it may 
take note of what is being done or left undone in the present day at the intellectual 
centres where thought and inquiry should be most active. 

MIND will include among its contributors some of the foremost workers in psy- 
chology and philosophy on the Continent and in America. 

Writers will sign and be alone responsible for their contributions. MIND will 
not be the organ ot any philosophical school, unless it be held the mark of a school 
to give prominence to psychological inquiry. 

Correspondence will be printed if it communicates new facts of scientific impor- 
tance, or expresses reasoned opinions. 



N. B. — The Review will not generally extend beyond 128 pages. Price, $4.00 
per year. 

D. APPLETON .& CO., Publishers, 

549 & 551 Broadway, New York. 



DESCRIPTIVE CATALOGUE 



OF 



MEDICAL WORKS 




INDEX OF SUBJECTS 



PAGE 

Anatomy 15 

Anaesthesia 25 

Acne 31 

Body and Mind 17 

Breath, and Diseases which give it a Fetid 
Odor 15 



Cerebral Convolutions 7 

Chemical Examination of the Urine in Dis- 
ease 8 

Chemical Analysis 13 

Technology 30 

Chemistry of Common Life 16 

Clinical Electro-Therapeutics 10 

" Lectures and Essays 31 

Comparative Anatomy 6 

Club-foot 24 



Diseases of the Nervous System 

" " " Bones 

" " Women 

" " theChest 

" " Children 

" " the Eectum 

" " the Ovaries 

Emergencies 

Electricity and Practical Me&cine 

Foods 

Galvano-Therapeutics 

Hospitalism 

Histology and Histo-Chemistry of Man. 

Infancy 

Insanity in its Relation to Crime 

Materia Medica and Therapeutics 

Medical Journal 

Mental Physiology 



24, 



PAGE 

Midwifery 25, 26 

Mineral Springs ... 29 

Neuralgia 3 

Nervous System 11, 12 

Nursing 22 

Obstetrics 4, 7, 25 

Ovarian Tumors 23 

" Diagnosis and Treatment 30 

Paralysis from Brain-Disease 31 

Physiology 9, 10 

Physiology of Common Life 16 

Physiology and Pathology of the Mind 17 

Physiological Effects of Severe Muscular 

Exercise 11 

Pulmonary Consumption 5 

Practical Medicine 20 

Physical Cause of the Death of Christ 25 

Popular Science 32 

Puerperal Diseases 2 

Eeports 4 

Eecollections of Past Life 14 

" of the Army of the Potomac . . 16 

Eesponsibility in Mental Diseases 18 

Sea-Sickness 2 

Surgical Pathology 5 

" Diseases of the Male Genito-Uri- 

nary Organs 27 

Surgerv 7 

" * Orthopedic 31 

Syphilis .\ 27 

Science 30, 32 

Skin-Diseases 21 

Therapeutics 31 

Uterine Therapeutics 26 

Winter and Spring 4 



D. APPLETON & CO., 

PUBLISHERS AND IMPORTERS, 

549 & 551 BROADWAY, NEW YORK. 
1876. 



CATALOGUE 

OF 

MEDICAL WORKS. 



ANSTIE. 

IN CUr2,lg"13., and Diseases which resemble it. 

By FRANCIS E. ANSTIE, M. D., F. R. C. P., 

Senior Assistant Physician to Westminster Hospital ; Lecturer on Materia Medica in "Westminster 
Hospital School; and Physician to the Belgrave Hospital for Children; Editor of "The 
Practitioner" (London), etc. 

1 vol., 12mo. Cloth, $2.50. 

" It is a valuable contribution to scientific medicine." — The Lancet (London). 

BARKER 
The Puerperal Diseases, cimimi Lectures 

delivered at JBellevue Hospital. 

By FORDYCE BARKER, M. D., 

Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical 
College; Obstetric Physician to Bellevue Hospital; Consulting Physician to the New York 
State Woman's Hospital ; Fellow of the New York Academy of Medicine ; formerly Presi- 
dent of the Medical Society of the State of New York ; Honorary Fellow of the Obstetrical 
Societies of London and Edinburgh ; Honorary Fellow of the Koyal Medical Society of 
Athens, Greece, etc., etc., etc. 

Third Edition. 1 vol., 8vo. Cloth. 526 pages. Price, S5 ; Sheep, $6. 

"For nearly twenty years it has been my duty, as well as my privilege, to give clinical lect- 
ures at Bellevue Hospital, on midwifery, the puerperal and the other diseases of women. This 
volume is made up substantially from phonographic reports of the lectures which I have given 
on the puerperal diseases. Having had rather exceptional opportunities for the study of these 
diseases. I have felt it to be an imperative duty to utilize, so far as lay in my power, the advan- 
tages which I have enjoyed for the promotion of science, and, I hope, for the'interests of human- 
ity. In many subjects, such as albuminuria, convulsions, thrombosis, and embolism, septicaemia, 
and pyaemia, the advance of science has been so rapid as to make it necessary to teach something 
new every year. Those, therefore, who have formerly listened to my lectures on these subjects, 
and who now do me the honor to read this volume, will not be surprised to find, in many par- 
ticulars, changes in pathological views, and often in therapeutical teaching, from doctrines before 
inculcated. At the present day, for the first time in the history of the world, the obstetric de- 
partment seems to be assuming its proper position, as the highest branch of medicine, if its rank 
be graded by its importance to society, or by the intellectual culture and ability required, as 
compared with that demanded of the physician or the surgeon. A man may become eminent as 
a physician, and yet know very little of obstetrics ; or he may be a successful and distinguished 
surgeon, and be quite ignorant of even the rudiments of obstetrics. But no one can be a really 
able obstetrician unless he be both physician and surgeon. And, as the greater includes the less, 
obstetrics should rank as the highest department of our profession."— From Author's Preface. 



On Sea-sickness, 



By FORDYCE BARKER, M. D. 
1 vol., 16mo. 36 pp. Flexible Cloth, 75 cents. 

Beprinted from the New York Medical Journal. By reason of the great demand for the 
number of that journal containing the paper, it is now presented in book form, with such pre- 
scriptions added as the author has found useful in relieving the suffering from sea-sickness. 



D. Appleton <Jb Go's Medical Publications. 



BARNES. 

Obstetric Operations, including the Treatment of 
Haemorrhage, and forming a Guide to the Management 
of Difficult Labor. 

By ROBERT BARNES, M. D., London, F. R. C. P., 

Obstetric Physician and Lecturer on Obstetrics and the Diseases of "Women and Children to St. 
George's Hospital ; Examiner in Obstetrics to the Koyal College of Physicians and the Eoyal 
College of Surgeons ; President of the Metropolitan Branch of the British Medical Associa- 
tion ; late Examiner to the University of London ; formerly Obstetric Physician to the Lon- 
don and to St. Thomas Hospitals ; and late Physician to the Eastern Division of the Eoyal 
Maternity Charity. 

Third Edition. Kevised and extended. 1 vol., 8vo. 606 pages. Cloth, $4.50. 

" Such a work as Dr. Barnes's was greatly needed. It is calculated to elevate the practice of 
the obstetric art in this country, and to be of great service to the practitioner." — Lancet. 

"The book of Dr. Barnes is not. properly speaking, a dogmatic treatise on obstetric opera- 
lions. It is a series of original lectures, comprising, at one and the same time, a practical analysis 
-of the serious accidents in parturition, the reasoned-out indications for, and the most judicious 
researches in the manner of operating, the method to choose, the instrument to prefer, and the 
-details of the manoeuvres required to insure success. The clearness of the style is perfect. The 
order, without being altogether rigorous, is what it is abk' to be generally in a series of clinical 
lectures. The description of the instruments, the application of the forceps, cephalotripsy, em- 
bryotomy, Caesarean section, the practical reflections on narrowing and malformation of the pel- 
vis, ruptures of the uterus, placenta prsevia, haemorrhage, and, in fact, all the grand questions in 
obstetrics are treated with accurate good sense. At each instant, by some remark or other, is 
revealed a superior mind, ripened by having seen much and meditated much." — From Preface 
to the French Edition by Prof. Pajot. 

BASTIAN. 
Paralysis from Brain Disease in its 

Common Forms. 

By H. CHARLTON BASTIAN. M. A., M. D., F. R. S., 

Fellow of the Eoyal College of Physicians ; Professor of Pathological Anatomy in University 
College. London: Physician to University College Hospital; and Senior Assistant Physician 
to the National Hospital for the Paralyzed and Epileptic. 

With Illustrations. 1 vol., 12mo. Cloth. $1.75. 

PEEFACE. 

These Lectures were delivered in University College Hospital last year, at a time when I was 
doing duty for one of the senior physicians, and during the same year — after they had been re- 
produced from very full notes taken by my friend Mr. John T vveedy — they appeared in the pages 
•of The Lancet. 

They are now republished at the request of many friends, though only after having undergone 
a very careful revision, during which a considerable quantity of new matter has been added. It 
would have been easy to have very much increased the size of the book by the introduction of a 
larger number of illustrative cases, and by treatment of many of the subjects at greater length, 
but this the author has purposely abstained from doing, under the belief that in its present lorm 
it is likely to prove more acceptable to students, and also perhaps more useful to busy practi- 
tioners. 

Notwithstanding its defects and many shortcomings, the author is not without a hope that 
this little book may be considered in some measure to supply a deficiency which has long existed 
in medical literature No dejmrtment of medicine stands more in need of being represented in 
a text book of moderate compass; so that, imperfect as it is, this small work may perhaps be of 
6ome service till it is superseded by something better. In it the author has endeavored to treat 
the subject with more precision than has hitherto been customary, and, while the lectures contain 
some novelties in method and mode of exposition, he hopes they may also be found not unfaith- 
fully to embody the principal facts at present known concerning this very important class of * 
diseases. 



4 D. Appleton & 06? s Medical Tublications. 

BENNET. 
On the Treatment of Pulmonary Con- 

sumption, by Hygiene, Climate, and Medicine, in its 
Connection with Modern Doctrines. 

By JAMES HENRY BENNET, M. D., 

Member of the Royal College of Physicians, London ; Doctor of Medicine of the University of Paris, etc., etc. 

1 vol., thin 8vo. Cloth, Si .50. 

An interesting and instructive work, written in the strong, clear, and lucid manner which appears in all the con- 
tributions of Dr. Bennet to medical or general literature. 

" We cordially commend this book to the attei.tion of all, for its practical common-sense views of the nature and 
treatment of the scourge of all temperate climates, pulmonary consumption." — Detroit Review of Medicine. 

Winter and Spring on the Shores of 

the Mediterranean ; or, the Riviera, Mentone, Italy r 
Corsica, Sicily, Algeria, Spain, and Biarritz, as Win- 
ter Climates. 

This work embodies the experience of ten winters and springs passed by Dr. Bennet on the shores of the Mediter- 
ranean, and contains much valuable information for physicians in relation to the health- restoring climate of the re- 
gions described. 

1 vol., 12mo. 621 pp. Cloth, $3.50. 

" Exceedingly readable, apart from its special purposes, and well illustrated." — Evening Commercial, 
" It has a more substantial value for the physician, perhaps, than for any other class or profession. . . . We com- 
mend this book to our readers as a volume presenting two capital qualifications — it is at once entertaining and instruc- 
tive."—^. Y. Medical Journal. 

BILLROTH. 
General Surgical Pathology and The- 

rapeutics, in Fifty Lectures. A Text-booh for Students 
and Physicians. 

By Dr. THEODOR BILLROTH. 

Translated from the Fifth German Edition, -with the special permission of the Author, by 
CHARLES E. HACKLEY, A. M., M. D., 

Surgeon to the New York Eye and Ear Infirmary ; Physician to the New York Hospital ; Fellow of the New York 
Academy of Medicine, etc. 

1 vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, $3.00. 

Professor Theodor Billroth, one of the most noted authorities on Surgical Pathology, gives in this volume a complete 
resume of the existing state of knowledge in this branch of medical science. The fact of this publication going through 
four editions in Germany, and having been translated into French, Italian, Russian, and Hungarian, should be som» 
guarantee for its standing. 

" The want of a book in the English language, presenting in a concise form the views of the German pathologists, 
has long been felt ; and we venture to say no book could more perfectly supply that want than the present volume, 
. . . We would strongly recommend it to all who take any interest in the progress of thought and observation in surgi- 
cal pathology, and surgery." — The Lancet, 

" We can a?sure our readers that they will consider neither money wasted in its purchase, nor time in its perusal. ,r 
— The Medical Investigator. 

CARPENTER. 
Principles of Mental Physiology, with 

their Applications to the Training and Discipline of the 
Mind and the Study of its Morbid Conditions. 
By WM. B. CARPENTER, M. D., LL. D , F. R. S., F. L. S., F. G. S., 

Begistrar of the University of London ; Corresponding Member of the Institute of France and of the American Philo- 
sophical Society, etc. 

1 vol., 8vo. Price, $3.00. 

"Among the numerous eminent writers this country has produced, none are more deserving of praise for having at- 
tempted to apply the results of Physiological Research to the expl mation of the mutuil relations of the mind and 
body than Dr. Carpenter. To him belongs the merit of having scientifically studied and of having in many instances- 
supplied a rational explanation of those phenomena which, under the names of mesmerism, spirit-rapping, electro-bi- 
ology, and hypnotism, have attracted so large an amount of attention during the last twenty years. . . . We must 
conclude by recommending Dr. Carpenter's work to the members of our own profession as applying raany facts, that 
have hitherto stood isolated, to the explanation of the functions of the brain and to psychological processes generally." 
— The Lancet. 



D. Appleton & CoSs Medical Publications. 5 

COMBE. 

The Management of Infancy, Physiologi- 
cal and Moral. Pntended chiefly for the Use of 
Parents. 

By ANDREW COMBE, M. D. 

REVISED AND EDITED 

By Sir JAMES CLARK, K. C. B., M. D., F. R. S., 

Physician-in-ordinary to the Queen. 

First American from the Tenth London Edition. 1 vol., 12mo. 302 pp, 

Cloth, 81.50. 

"This excellent little book should be in the hand of every mother of a family; and, if some 
of our lady friends would master its contents, and either bring U p their children by the light of 
its teachings, or communicate the truths it contains to the poor by whom they are surrounded, 
we are convinced that they would effect infinitely more good than by the distribution of any 
number of tracts whatever. . . . We consider this work to be one of "the few popular medical 
treatises that any practitioner may recommend to his patients ; and, though, if its precepts are 
followed, he will probably lose a few guineas, he will not begrudge them if he sees his friend's 
children grow up healthy, active, strong, and both mentally and physically capable." — The 
Lancet. 

CHAUVEAU. 
The Comparative Anatomy of the 

Domesticated Animals. 

By A. CHAUVEAU, 

PEOFESSOE AT THE LYONS VETEELNAEY SCHOOL. 

Second edition, revised and enlarged, with the cooperation of S. ARLOIKG, 
late Principal of Anatomy at the Lvons Veterinary School ; Professor at the 
Toulouse Veterinary School. Translated and edited by GEORGE FLEMING, 
F. R. G. S., M. A. I., Veterinai y Surgeon, Royal Engineers. 

1 vol., 8vo. Cloth. 957 pp., with 450 Illustrations. Price, $6.00. 



OPINIONS OF THE PRESS. 

" This is a valuable work, well conceived and well executed by the authors, MM. Chauveau 
-and Arloing, and well translated by Mr. Fleming. It is rather surprising how few works exist, 
In any language, in which the anatomy of the commoner animals, domestic and otherwise, is 
given with any approach to detail. Systematic works there are in abundance, but, if the student 
be desirous of ascertaining any particular point, such as the position and branches of the 
pneumogastric or sympathetic nerves, or the homologue of a given muscle in several different 
animals, he may search all day ere he find it. The work before us appears to be well adapted to 
meet this difficulty. 

" The illustrations are very numerous, and Mr. Fleming has introduced a large number that 
are not contained in the original work. 

" Taking it altogether, the book is a very welcome addition to English literature, and great 
.credit is due to Mr. Fleming for the excellence of the translation, and the many additional notes he 
has appended to Chauveau*s treatise." — Lancet (London}. 

" The want of a text-book on the Comparative Anatomy of the Domesticated Animals has 
long been felt. . . . The descriptions of the text are illustrated and assisted by no less than 450 
excellent woodcuts. In a work which ranges over so vast a field of anatomical detail and de- 
scription, it is difficult to select any one portion for review, but our examination of it enables us 
to 6peak in high terms of its general excellence. . . . The care and attention with which hippot- 
4Hny has been cultivated on the Continent are illustrated by every page in M. Chauveau's work- 
•—Medical Times and Gazette (Londan), 



6 D. Applet on & CoSs Medical Publications. 

DAVIS. 

V^OnSCrVcltlVe OtirgCry, as exhibited in remedying 
some of the Mechanical Causes that operate injuriously 
both in Health and Disease. With Illustrations. 

By HENRY G. DAVIS, M. D., 

Member of the American Medical Association, etc., etc. 
1 vol., 8vo. 315 pp. Cloth. $3.00. 

The author has enjoyed rare facilities for the study and treatment of certain classes of disease;. 
and the records here presented to the profession are the gradual accumulation of over thirty 
years'' investigation. 

"Dr. Davis, bringing, as he does to his specialty, a great aptitude for the solution of mechani- 
cal problems, takes a high rank as an orthopedic surgeon, and his very practical contribution to 
the literature of the subject is both valuable and opportune. We deem it worthy of a place in 
every physician's library. The style is unpretending, but trenchant, graphic, and, best of all,, 
quite intelligible."— Medical Record. 

ECKER 
The Cerebral Convolutions of Man, 

represented according to Personal Investigations, espe- 
cially on their Development in the Foetus, and with ref- 
erence to the Use of Physicians. 

By ALEXANDER ECKER, 

Professor of Anatomy and Comparative Anatomy in the University of Freiburg. 

Translated from the German by Robert T. Edes, M. D. 

1 vol., 8vo. 87 pp. $1.25. 

"The work of Prof. Ecker is noticeable principally for its succinctness and clearness, avoiding 
long discussions on undecided points, and yet sufficiently furnished with references to make easy 
its comparisons with the labors of others in the same direction. 

" Entire originality in descriptive anatomy is out of the question, but the facts verified by our 
author are here presented in a more intelligible manner than in any other easily-accessible work. 

"The knowledge to be derived from this work is not furnished by any other text-book in the 
English language." — Boston Medical and Surgical Journal, January 20, 1873. 

ELLIOT. 

Obstetric ClmiC. A Practical Contribution to the Study 
of Obstetrics, and the Diseases of Women and Children.. 
By the late GEORGE T. ELLIOT, M. D., 

Late Professor of Obstetrics and Diseases of Women and Children in the Bellevue Hospital* 
Medical College ; Physician to Bellevue Hospital and to the New York Lying-in Asylum ; 
Consulting Physician to the Nursery and Child's Hospital ; Consulting Surgeon to the State- 
Woman's Hospital ; Corresponding Member of the Edinburgh Obstetrical Society and of the 
Eoyal Academy of Havana; Fellow of the N. Y. Academy of Medicine; Member of the- 
County Medical Society, of the Pathological Society, etc., etc. 

1 vol., 8vo. 458 pp. Cloth, $4.50. 

This work is, in a measure, a resume of separate papers previously prepared by the late Dr. 
Elliot; and contains, besides, a record of nearly two hundred important and difficult cases in mid- 
wifery, selected from his own practice. It has met with a hearty reception, and has received the 
highest encomiums both in this country and in Europe. 



D. Appleton & Co?s Medical Publications. 7 

FREY. 
The Histology and Histo-Chemistry 

of Man. A Practical Treatise on the Elements of Com- 
position a?id Structure of the Human Body. 

By HEINKICH FREY, 

Professor of Medicine in Zurich. 

Translated from the Fourth German Edition, by Arthur E. J. Barker, 

Surgeon to the City of Dublin Hospital: Demonstrator of Anatomy, Royal College of Surgeons, 
Ireland; Yisiting Surgeon, Convalescent Home, Stillorgan ; and revised by the Author. 
With 680 Engravings. 

1 vol., 8vo. Cloth, $5.00; Sheep, 86.00. 

CONTENTS. 
The Elements of Composition and of Structure of the Body : Elements of Composition— Al- 
buminous or Protein Compounds, Hsemoglobuhn, Histogenic Derivatives of the Albuminous 
Substances or Albuminoids, the Patty Acids and Fats, the Carbohydrates, Non-Nitrogenous 
Acids, Nitrogenous Acids, Amides, Amido-Acids, and Organic Bases, Animal Coloring Matters, 
Cyanogen Compounds, Mineral Constituents ; Elements of Structure— the Cell, the Origin of the 
Remaining Elements of Tissue ; the Tissues of the Body — Tissues composed of Simple Cells, with 
Fluid Intermediate Substance, Tissues composed of Simple Cells, with a small amount of Solid 
Intermediate Substance, Tissues belonging to the Connective-Substance Group, Tissues com- 
posed of Transformed, and, as a rule, Cohering Cells, with Homogeneous, Scanty, and more or less 
Solid Intermediate Substance, Composite Tissues: The Organs of the Body— Organs of the 
A r egetative Type, Organs of the Animal Group. 

FLINT, 

Manual of Chemical Examination of 

the Urine in Disease. With Brief Directions for the 
JEJxamination of the most Common Varieties of Urinary 
Calculi. 

By AUSTIN FLINT, Jb., M.D., 

Professor of Physiology and Microscopy in the Bellevue Hospital Medical College ; Fellow of the 
New York Academy of Medicine ; Member of the Medical Society of the County of New 
York ; Resident Member of the Lyceum of Natural History in the City of New York, etc. 

Third Edition, revised and corrected. 1 vol., 12mo. 77 pp. Cloth, $1.00. 

The chief aim of this little work is to enable the busy practitioner to make for 
himself, rapidly and easily, all ordinary examinations of Urine ; to give him the 
benefit of the author's experience in eliminating little difficulties in the manipula- 
tions, and in reducing processes of analysis to the utmost simplicity that is con- 
sistent with accuracy. 

" "We do not know of any work in English so complete and handy as the Manual now offered 
to the Profession by Dr. Flint, and the high scientific reputation of the author is a sufficient 
guarantee of the accuracy of all the directions given"— Journal of Applied Chemistry. 

""We can unhesitatingly recommend this Manual." — Psychological Journal. 

"Eminently practical." — Detroit Review of Medicine. 



8 D. Appleton dc Co.'s Medical Publications. 

FLINT. 

The Physiology of Man. Designed to rep- 
resent the Existing State of Physiological Science as 
applied to the Functions of the Human Body. 

By AUSTIN FLINT, Jr., M. D., 

Professor of Physiology and Microscopy in the Bellevue Hospital Medical College, and in the 
Long Island College Hospital; Fellow of the New York Academy of Medicine; Microscopist 
to Bellevue Hospital. 

Uew and thoroughly revised Edition. In Five Volume3. 8vo. Tinted Paper. 
Volume I. — The Blood ; Circulation/ Respiration. 

8vo. 502 pp. Cloth, $4.50. 

" If the remaining portions of this work are compiled with the same care and 
accuracy, the whole may vie with any of those that have of late years been pro- 
duced in our own or in foreign languages." — British and Foreign Medico- Chirurgi- 
cal Review. 

" As a book of general information it will be found useful to the practitioner, 
and, as a book of reference, invaluable in the hands of the anatomist and physi- 
ologist." — Dublin Quarterly Journai of Medical Science. 

" The complete work will prove a valuable addition to our systematic treatises 
on human physiology." — The Lancet. 

" To those who desire to get in one volume a concise and clear, and at the 
same time sufficiently full resume of ' the existing state of physiological science,' 
we can heartily recommend Dr. Flint's work. Moreover, as a work of typographi- 
cal art it deserves a prominent place upon our library-shelves. Messrs. Appleton 
& Co. deserve the thanks of the profession for the very handsome style in which 
they issue medical works. They give us hope of a time when it will be very 
generally believed by publishers that physicians' eyes are worth saving." — Medi- 
cal Gazette. 

Yolunie II. — Alimentation; Digestion; Absorption; 
I/ymph and Chyle. 

8vo. 556 pp. Cloth, $4.50. 

" The second instalment of this work fulfils all the expectations raised by the 
perusal of the first. . . . The author's explanations and deductions bear 
evidence of much careful reflection and study. ... The entire work is one 
of rare interest. The author's style is as clear and concise as his method i& 
studious, careful, and elaborate." — Philadelphia Inquirer. 

" We regard the two treatises already issued as the very best on human physi- 
ology which the English or any other language affords, and we recommend them 
with thorough confidence to students, practitioners, and laymen, as models of 
literary and scientific ability." — N. Y. Medical Journal. 

" We have found the style easy, lucid, and at the same time terse. The prac- 
tical and positive results of physiological investigation are succinctly stated, 
without, it would seem, extended discussion of disputed points. "—Boston Medical 
and Surgical Journal. 

" It is a volume which will be welcome to the advanced student, and as a 
work of reference." — The Lancet. 

" The leading subjects treated of are presented in distinct parts, each of which 
is designed to be an exhaustive essay on that to which it refers."— Western Jour- 
nal of Medicine. 



D. Appleton & CoSs Medical Publications. 9 

Flint's Physiology. Volume III.— Secretion; Ex- 
cretion; Ductless Glands ; Nutrition; Animal Heat; 
Movements; Voice and Speech. 

8vo. 526 pp. Cloth, $4.50. 

" Dr. Flint's reputation is sufficient to give a character to the book among the 
-profession, where it will chiefly circulate, and many of the facts given have been 
verified by the author in his laboratory and in public demonstration." — Chicago 
Courier. 

" The author bestows judicious care and labor. Facts are selected with dis- 
crimination, theories critically examined, and conclusions enunciated with com- 
mendable clearness and precision." — American Journal of the Medical Sciences. 

Volume IV. — The Nervous System. 

8vo. Cloth, $4.50. 

This volume embodies the results of exhaustive study, and of a long and 
laborious series of experiments, presented in a manner remarkable for its strength 
and clearness. No other department of physiology has so profound an interest 
for the modern and progressive physician as that pertaining to the nervous 
system. The diseases of this system are now engaging the study and attention 
of some of the greatest minds in the medical world, and in order to follow their 
brilliant discoveries and developments, especially in connection with the science 
of electrology, it is absolutely necessary to obtain a clear and settled knowledge 
of the anatomy and physiology of the nervous system. It is the design of this 
work to impart that knowledge free from the perplexing speculations and uncer- 
tainties that have no real value for the practical student of medicine. The 
author boldly tests every theory for himself, and asks his readers to accept noth- 
ing that is not capable of demonstration. The properties of the cerebro-spinal, 
nervous, and sympathetic systems are treated of in a manner at once lucid, 
thorough, and interesting. 

Although this volume is one, perhaps the most important one, of the author's 
admirable series in the Physiology of Man, it is nevertheless complete in itself, 
-and may be safely pronounced indispensable to every physician who takes a pride 
And interest in the progress of medical science. 

Volume V. — Special Senses ; Generation. 
8vo. Cloth, S4.50. 

" The present volume completes the task, begun eleven years ago, of preparing 
a work, intended to represent the existing state of physiological science, as ap- 
plied to the functions of the human body. The kindly reception which the first 
four volumes have received has done much to sustain the author in an under- 
taking, the magnitude of which he has appreciated more and more as the work 
has progressed. 

"In the fifth and last volume, an attempt has been made to give a clear account 
of the physiology of the special senses and generation, a most difficult and delicate 
undertaking. . . . 

"Finally, as regards the last, as well as the former volumes, the author can 
only say that he has spared neither time nor labor in their preparation ; and the 
imperfections in their execution have beeu due to deficiency in ability and oppor- 
tunity. He indulges the hope, however, that he has written a book which may 
assist his fellow-workers, and interest, not only the student and practitioner of 
medicine, but some others who desire to keep pace with the progress of Natural 
Science." — Extracts from Preface. 



10 D. Appleton & CoSs Medical Publications. 



Flint's Text-Book of Human Physi- 

ology, for the Use of Students and Practitioners of Medi- 
cine. 

In one large octavo volume of 978 pages, elegantly printed on fine paper, and 
profusely illustrated with three Lithographic Plates and 313 Engrav- 
ings on Wood. Price, in cloth, $6.00 ; sheep, f7.00. 

While Prof. Flint's " Physiology of Mar," in five octavo volumes, also published by D. Apple- 
ton & Co., is invaluable as a book of reference, giving an epitome of the literature of physiology, 
with copious references to other authors, the publishers have appreciated the necessity for a new 
text-book, for the use of students and practitioners of medicine. 

This new work is intended to meet this pressing want, and it contains most of the facts pre- 
sented in the larger treatise, without historical references or discussions of minor and contro- 
verted questions. The high reputation of the author as a public teacher, and the success of th& 
larger treatise, render it certain that the " Text-book " will be admirably adapted to the wants of 
medical students. 

In the " Text-book, 1 ' all important points connected with Human Physiology are treated of" 
fully and clearly, and many subjects, such as the Nervous System, the Special Senses, etc., the 
treatment of which is barren and unsatisfactory in many works written or republished in this- 
country, are brought fully up to the requirements of the day. 

The publishers have given great attention to the execution of the illustrations, few of which 
are familiar to American readers. It being almost impossible to reproduce some of the cuts 
taken from foreign works, they have succeeded in obtaining abroad about one hundred electro- 
types from the original engravings contained in Sappey's great work upon Anatomy, which are 
unequaled in their mechanical execution. The subject of Generation is also illustrated by litho- 
graphic plates taken from Haeckel. 

The great care necessary in the printing of the elaborate illustrations has caused an unavoid- 
able delay in the appearance of the work; but the publishers feel confident that it will fully meet 
their expectations, and justify the reputation of its author. 

" In preparing this text-book for the use of students and practitioners of medicine, I have en- 
deavored to adapt it to the wants of the profession, as they have appeared to me after a consider- 
able experience as a public teacher of human physiology. My large treatise in five volumes is 
here condensed, and I have omitted bibliographical citations and matters of purely historical in- 
terest. Many subjects, which were considered rather elaborately in my larger work, are here 
presented in a much more concise form. 1 have added, also, numerous illustrations, which I 
hope may lighten the labors of the student. A few of these are original/but by far the greatest 
part has been selected from reliable authorities. I have thought it not without historical interest 
to reproduce exactly some of the classical engravings from the works of great discoverers, such 
as illustrations contained in the original editions of Fabricius, Harvey, and Asellius. In addition, 
I have reproduced a few of the beautiful microscopical photographs taken at the United States 
Army Medical Museum, under the direction of Dr. J. J. Woodward, to whom I here express my 
grateful acknowledgments. I have also to thank M. Sappey for his kindness in furnishing 
electrotypes of many of the superb engravings with which his great work upon Anatomy is illus- 
trated. 

" My work in five volumes was intended as a book of reference, which I hope will continue to 
be useful to those who desire an account of the literature of physiology, as well as a statement of 
the facts of the science. I have always endeavored, in public teaching, to avoid giving undue 
prominence to points in which I might myself be particularly interested, from having made them 
subjects of special study or of original research. In my text-book I have carried out the same 
idea, striving to teach, systematically and with uniform emphasis, what students of medicine are 
expected to iearn in physiology, and avoiding elaborate discussions of subjects not directly con- 
nected with practical medicine, surgery, and obstetrics. While I have referred to my original 
observations upon the location of the sense of want of air in the general system, the new ex- 
cretory function of the liver, the function of glycogenesis, the influence of muscular exercise upon 
the elimination of urea, etc., I have not considered these subjects with great minuteness, and 
have generally referred the reader to monographs for the details of my experiments. 

"Finally, in presenting this work to the medical profession, I cannot refrain from an expres- 
sion of my acknowledgments to the publishers, who have spared nothing in carrying out my 
views, and have devoted special pains to the mechanical execution of the illustrations/ 1 — Author^ 
Preface. 



D. Appleton <fb Co.'s Medical Publications. II 

FLINT. 
On the Physiological Effects of Severe 

and Protracted Muscular Exercise. With special refer- 
ence to its Influence upon the Excretion of Nitrogen, 
By AUSTIN FLINT, Jr., M. D., 

Professor of Physiology in the Bellevue Hospital Medical College, New York, etc., etc. 
1 vol., 8vo. 91 pp. Cloth, $2.00. 

This monograph on the relations of Urea to Exercise is the result of a thorough and carefur 
investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian. The 
chemical analyses were made under the direction of R. 0. Doremus, M. D., Professor of Chemistry 
and Toxicology in the Bellevue Hospital Medical College, by Mr. Oscar Loew, his assistant. The 
observations were made with the cooperation of J. C. Dalton, M. D . Professor of Physiology in 
the College of Physicians and Surgeons; Alexander B. Mott, M. D., Professor of Surgical Anat- 
omy; W. H. Van Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., Pro- 
fessor of the Principles ana Practice of Medicine ; W. A. Hammond, M. D., Professor of Diseases 
of the Mind and Nervous System— all of the Bellevue Hospital Medical College. 

" This work will be found interesting to every physician. A number of important results^ 
were obtained valuable to the physiologist.' 1 — Cincinnati Medical Repertory. 

HAMILTON. 
Clinical Electro -Therapeutics. (Medtcaiand 

Surgical.) A Manual for Physicians for the Treatment 
more especially of Nervous Diseases. 

By ALLAN" McLANE HAMILTON, M. D., 

Physician in charge of the New York State Hospital for Diseases of the Nervous System ; Mem- 
ber of the New York Neurological and County Medical Societies, etc., etc. 

With Numerous Illustrations. 1 vol., 8vo. Cloth. Price, $2.00. 

This work is the compilation of well-tried measures and reported cases, and is intended as a 
simple guide for the general practitioner. It is as free from confusing theories, technical terms,, 
and unproved statements, as possible. Electricity is indorsed as a very valuable remedy in cer- 
tain diseases, and as an invaluable therapeutical means in nearly all forms of Nervous Disease ;. 
but not as a specific for every human ill, mental and physical. 

HAMMOND. 
Insanity in its Relations to Crime, a 

Text and a Commentary. 

By WILLIAM A. HAMMOND, M. D. 
1 vol., 8vo. 77 pp. Cloth, $1.00. 

" A part of this essay, under the title ' Society versus Insanity, 1 was contributed to Putnam\<r 
Magazine, for September, 1S70. The greater portion is now first published. The importance of 
the subject considered can scarcely be over-estimated, whether we regard it from the stand-point 
of science or social economy; and, if I have aided in its elucidation, my object will have been at- 
tained.'"— From Author's Preface. 

Clinical Lectures on Diseases of the 

Nervous System. Delivered at the Bellevue Hospital 
Medical College. 

By WILLIAM A. HAMMOND, M. D., 

Professor of Diseases of the Mind and Nervous System, etc. Edited, with Notes, by T. M. Bv 

CROSS, M. D., Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. 

In one handsome volume of 300 pages. Price, $3.50. 



12 D. Appleton <& Co.'s Medical Publications. 



HAMMOND. 
A Treatise on Diseases of the Nervous 

System. 

By WILLIAM A. HAMMOND, M. D., 

Professor of Diseases of the Mind and Nervous System in the Medical Department of the Univer- 
sity of the City of New York; President of the New York Neurological Society, etc., etc. 

Sixth Edition. 1 vol., 8vo. Strong Cloth Binding, $6.00; Sheep, $7.00. 

The remarkable success attendant on the issue of the five previous editions of this work in 
less than four years has encouraged the author and publishers to attempt to make the work still 
more worthy the confidence of the medical profession. A great part of the treatise has been en- 
tirely rewritten, and several new chapters have been added. By a change in type, and enlarging 
the page, the new matter, amounting to one-half of the original work, has been added without 
increasing materially the bulk of the volume. Many new illustrations have been incorporated in 
the text, and the whole treatise has been brought fully up to the present time. In addition to 
the fund of personal observation and experience adduced by Prof. Hammond, the labors of Eng- 
lish, French, and German writers have received due attention. 

Among the diseases considered in the present edition, which were not treated of in the former 
editions, are : Chronic Verticalar Meningitis ; Chronic Basilar Meningitis ; Cervical Pachy -Men- 
ingitis; Spinal Paralysis of Adults; Amyotrophic Lateral Spinal Sclerosis; Facial Atrophy; 
Organic Diseases of Nerves ; Chronic Alcoholic Intoxication ; Delirium Tremens ; Exophthalmic 
Goitre; and Anapeiratic Paralysis— paralysis induced by a frequent repetition of certain muscular 
actions. Besides which, extensive alterations and additions have been made to the remarks on 
other affections— the departments of Morbid Anatomy, Pathology, and Treatment, being espe- 
-cially amplified. 

NOTICES OF FOEMEE EDITIONS. 

" Free from useless verbiage and obscurity, it is evidently the work of a man who knows what 
he is writing about, and knows how to write about it." — Chicago Medical Journal. 

"Unquestionably the most complete treatise on the diseases to which it is devoted which has 
yet appeared in the English language." — London Medical Times and Gazette. 

" This is a valuable and comprehensive book ; it embraces many topics, and extends over a 
wide sphere. One of the most valuable parts of it relates to the Diseases of the Brain ; while the 
remaining portion of the volume treats of the Diseases of the Spinal Cord, the Cerebro-spinal 
System, the Nerve-Cells, and the Peripheral Nerves."— British Medical Journal. 

"The work before us is unquestionably the most exhaustive treatise, on the diseases to which 
it is devoted, that has yet appeared in English. And its distinctive value arises from the fact 
that the work is no mere rafflciamento of old observations, but rests on his own experience and 
practice, which, as we have before observed, have been very extensive." — American Journal of 
Syphilography. 

" The author of this work has attained a high rank among our brethren across the Atlantic 
from previous labors in connection with the disorders of the nervous system, as well as from 
various other contributions to medical literature, and he now holds the official appointments of 
Physician to the New York State Hospital for the Diseases of the Nervous System, and Professor 
of the same department in the Bellevue Hospital Medical College. The present treatise is the 
fruit of the experience thus acquired, and we have no hesitation in pronouncing it a most valu- 
able addition to our systematic literature." — Glasgow Medical Journal. 



D. Appleton & CoSs Medical Publications. 



15 



HOFFMANN. 
Manual of Chemical Analysis, <b applied 

to the Examination of Medicinal Chemicals and their 
Preparations. A Guide for the Determination of their 
Identity and Quality, and for the Detection of Impuri- 
ties and Adulterations. For the use of Pharmaceutists y 
Physicians, Druggists, and Manufacturing Chemists, and 
Pharmaceutical and Medical Students. 

By FRED. HOFFMANN, Phil. D. 

One vol., 8vo. Eichly Illustrated. Cloth. Frice, 83. 

SPECIMEN O? ILLUSTRATIONS. 




"This volume is a carefully -prepared work, and well up to the existing state of both the science 
and art of modern pharmacv. It is a hook which will find its place in every medical and phar- 
maceutical laboratory and library, and is a safe and instructive guide to medical students and 
practitioners of medicine. ,1 — American Journal of Science and Arts. 

In America this work has already met with general and unqualified approval; and in Europe 
is now beinsr welcomed as one of the best and most important additions to modern pharmaceu- 
tical literature. 

Send for descriptive circular. Address 

D. APPLETON & CO., 549 & 551 Broadway, N. Y. City. 



14 D. Appleton <b Co.'s Medical Publications, 

HOLLAND. 
Recollections of Past Life, 

By SIR HENRY HOLLAND, Bart., M. D., P. R. S., K. C. B., etc., 
President of the Royal Institution of Great Britain, Physician-in-Ordinary to the Queen, 

etc., etc. 

1 vol., 12mo, 351 pp. Price, Cloth, $2.00. 

A very entertaining and instructive narrative, partaking somewhat of the nature of 
autobiography and yet distinct from it, in this, that its chief object, as alleged by the 
writer, is not so much to recount the events of his own life, as to perform the office of 
chronicler for others with whom he came in contact aud was long associated. 

The " Life of Sir Henry Holland " is one to be recollected, and he has not erred in giv- 
ing an outline ol it to tbe public."— The Lancet. 

" His memory was — is, we may say, for he is still alive and in possession of all his 
faculties—stored with recollections of the most eminent men and women of this cen- 
tury. ... A life extending over a period of eighty-four years, and passed in the most 
active manner, in the midst of the best society, wldch the world has to offer, must neces- 
sarily be full of singular interest; and Sir Henry Holland has fortunately not waited until 
his memory lost its freshness before recalling some of the incidents in it." — The New 
York Times. 

HOWE. 

Emergencies, and How to Treat Them. 

The Etiology, Pathology, and Treatment of Accidents, 
Diseases, and Cases of Poisoning, which demand 
Prompt Attention. Designed for Students and Prac- 
titioners of Medicine. 

By JOSEPH W. HOWE, M. D., 

Clinical Professor of Surgery in the Medical Department of the University of New York 

Visiting Surgeon to Charity Hospital ; Fellow of the New York Academy 

of Medicine, etc., etc. 

1 vol., 8vo. Clotli, $3.00. 

" This work has a taking title, and was written by a gentlemen of acknowledged ability, tc 
fill a void in the profession. ... To the general practitioner in towns, villages, and in the 
country, where the aid and moral support of a consultation cannot be availed of, this volume 
will be recognized as a valuable help. We commend it to the profession. — Cincinnati Lancet 
and Observer. 

" This work' is certainly novel in character, and its usefulness and acceptability are as marked 
as its novelty. . . . The book is confidently recommended." — Richmond and Louisville Med- 
ical Journal. 

" This volume is a practical illustration of the positive side of the physician's life, a constant 
reminder of what he is to do in the sudden emergencies which frequently occur in practice. 
. . . The author wastes no words, but devotes himself to the description of each disease as if 
the patient were under his hands. Because it is a good book we recommend it most heartily to 
the profession."— Boston Medical and Surgical Journal. 

"This work bears evidence of a thorough practical acquaintance with the different branches 
of the profession. The author seems to possess a peculiar aptitude for imparting instruction 
as well as for simplifying tedious details. ... A careful perusal will amply repay the student 
and practitioner.'' —New York Medical Journal" . , 

"This is the best work of the kind we have ever seen.'V-Aw York Journal of Psychological 
Medicine. 



D. Appleton & Co.'s Medical Publications. 15 

HOWE. 
The Breath, and the Diseases which give 

it a Fetid Odor. With Directions for Treatment. 
By JOSEPH W. HOWE, M. D., 

• utnor of " Emergencies," " "Winter Homes," etc ; Clinical Professor of Surgery in the Medical 
Department of the University of New York; Visiting Surgeon to Charity and St. Francis 
Hospitals; Fellow of the New* York Academy of Medicine, etc. 

"It is somewhat remarkable that the subject of fetid breath, which occasions so much annoy- 
ance. . . . should have attracted so little attention from authors and investigators. Hence a 
thoroughly scientific exposition of the whole subject, such as Dr. Howe has given us, has long 
been a desideratum. ... This little volume well deserves the attention of physicians, to whom 
we commend it most highly. 11 — Chicago Medical Journal. 

"... To any one suffering from the affection, either in his own person or in that of his inti- 
mate acquaintances, we can commend this volume as containing all that is known concerning the 
subject, set forth in a pleasant style." — Philadelphia Medical Times. 

" This little work is on a subject that has heretofore been almost entirely ignored by medical 
authors, yet its importance is well known by every practitioner. . . . The author gives a succinct 
account of the diseased conditions in which a fetid breath is an important symptom, with his 
method of treatment. We consider the work a real addition to medical literature." — Cincinnati 
Medical Journal. 

HUXLEY AND YOUMANS. 
The Elements of Physiology and Hy- 

giene. With Numerous Illustrations. 

By THOMAS H. HUXLEY, LL. D., F.R.S., and 

WILLIAM JAY YOUMANS, M. D. 

New and Revised Edition. 1 vol., 12mo. 420 pp. $1.75. 

A text-book for educational institutions, and a valuable elementary work for students of medi- 
cine. The greater portion is from the pen of Professor Huxley, adapted by Dr. Youmans to the 
circumstances and requirements of American education. The eminent claim of Professor Hux- 
ley's "Elementary Physiology" is, that, while up to the times, it is trustworthy in its presenta- 
tion of the subject ; while rejecting discredited doctrines and doubtful speculations, it embodies 
the latest results that are established, and represents the present actual state of physiological 
knowledge. 

"A valuable contribution to anatomical and physiological science." — Religious Telescope. 

" A clear and well arranged work, embracing the latest discoveries and accepted theories." — 
Buffalo Commercial. 

"Teeming with information concerning the human physical economy."— Evening Journal. 

HUXLEY. 
The Anatomy of Vertebrated Animals. 

By THOMAS HENRY HUXLEY, LL. D., F. R. S., 

Author of "Man's Place in Nature," '• On the Origin of Species," " Lay Sermons and Addresses," 

etc. 

1 vol., 12mo. Cloth, $2.50. 

The former works of Prof. Huxley leave no room for doubt as to the importance and value of 
his new volume. It is one which will be very acceptable to all who are interested in the subject 
of which it treats. 

"This long-expected work will be cordially welcomed by all students and teachers of Com- 
parative Anatomy as a compendious, reliable, and, notwithstanding its small dimensions, most 
comprehensive guide on the subject of svhich it treats. To praise or to criticise the work of so 
accomplished a master of his favorite science would be equally out of place. It is enough to say 
that it realizes, in a remarkable degree, the anticipations which have been formed of it; and that 
it presents an extraordinary combination of wide, general views, with the clear, accurate, and 
succinct statement of a prodigious number of individual facts."— Nature. 



16 D, Appleton & CoSs Medical Publications, 

JOHNSON. 
The Chemistry of Common Life. 

Illustrated with numerous Wood Engravings. 
By JAMES F. JOHNSON, M. A., F. R. S., F. G. S., etc., etc., 

Author of " Lectures on Agricultural Chemistry and Geology," " A Catechism of Agricultural! 
Chemistry and Geology," etc. 

2 vols., 12mo. Cloth, $3.00. 
It has been the object of the author in this work to exhibit the 
present condition of chemical knowledge, and of matured scientific 
opinion, upon the subjects to which it is devoted. The reader will not 
be surprised, therefore, should he find in it some things which differ 
from what is to be found in other popular works already in his hands or 
on the shelves of his library. 

LETTERMAN. 
Medical Recollections of the Army of 

the Potomac. 

By JONATHAN LETTERMAN, M. D., 

Late Surgeon U. S. A., and Medical Director of the Army of the Potomac. 
1 vol., 8vo. 194 pp. Cloth, $1.00. 
" This account of the medical department of the Army of the Poto- 
mac has been prepared, amid pressing engagements, in the hope that 
the labors of the medical officers of that army may be known to an in- 
telligent people, with whom to know is to appreciate ; and as an affec 
tionate tribute to many, long my zealous and efficient colleagues, who, 
in days of trial and danger, which have passed, let us hope never to re- 
turn, evinced their devotion to their country and to the cause of hu- 
manity, without hope of promotion or expectation of reward." — Preface, 

" We venture to assert that but few who open this volume of medical annals, 
pregnant as they are with instruction, will care to do otherwise than finish them 
at a sitting." — Medical Record. 

" A graceful and affectionate tribute." — N. Y. Medical Journal. 

LEWES. 
The Physiology of Common Life. 

By GEORGE HENRY LEWES, 

Author of "Seaside Studies," "Life of Goethe," etc. 

2 vol3., 12mo. Cloth, $3.00. 

The object of this work differs from that of all others on popular 

science in its attempt to meet the wants of the student, while meeting 

those of the general reader, who is supposed to be wholly unacquainted 

with anatomy and physiology. 



D. Appleton & Co.'s Medical Publications. 17 

MAUDSLEY. 
The Physiology and Pathology of the 

Mind. 

By HENRY MAUDSLEY, M. D., London, 
Fellow of the Eoyal College of Physicians ; Professor of Medical Jurisprudence in University Col- 
lege. London; President-elect of the Medico- Psychological Association; Honorary Member of 
the Medico-Psychological Society of Paris, of the Imperial Society of Physicians of Vienna, 
and of the Society for the Promotion of Psychiatry and Forensic Psychology of Vienna; 
formerly Kesident Physician of the Manchester .Royal Lunatic Asylum, etc., etc. 

1 vol., 8vo. 422 pp. Cloth, $3.00. 

This work aims, in the first place, to treat of mental phenomena from a 
physiological rather than from a metaphysical point of view ; and, secondly, to 
bring the manifold instructive instances presented by the unsound mind to bear 
upon the interpretation of the obscure problems of mental science. 

"Dr. Maudsley has had the courage to undertake, and the skill to execute, what is, at least in 
English, an original enterprise." — London Saturday Review. 

" It is so full of sensible reflections and sound truths that their wide dissemination could not 
but be of benefit to all thinking persons. 11 '— Psychological Journal. 

" Unquestionably one of the ablest and most important works on the subject of which it 
treats that has ever appeared, and does credit to his philosophical acumen and accurate observa- 
tion. 11 — Medical Record. 

" We lay down the book with admiration, and we commend it most earnestly to our readers 
as a work of extraordinary merit and originality — one of those productions that are evolved only 
occasionally in the lapse of years, and that serve to mark actual and very decided advantages in 
knowledge and science. 11 — A 7 . Y. Medical Journal. 

Body and Mind : An Inquiry into their Con- 
nection and Mutual Influence, especially in reference to 
Mental Disorders; an enlarged and revised edition to 
which are added Psychological Essays. 

By HENRY MAUDSLEY, M. D., London, 

Author of "The Physiology and Pathology of the Mind.'" 

1 vol., 12mo. 155 pp. Cloth, $1.00. 

The general plan of this work may be described as being to bring man, both 
in his physical and mental relations, as much as possible within the scope of sci- 
entific inquiry. 

" A representative work, which every one must study who desires to know what is doing in the 
way of real progress, and not mere chatter, about mental physiology and pathology. 11 — Lancet. 
"It distinctly marks a step in the progress of scientific psychology.'" — The Practitiontr. 

Responsibility in Mental Diseases. 

By HENRY MAUDSLEY, M. D., London, 
Author of " Body and Mind, 11 " Physiology and Pathology of the Mind. 11 

1 vol., 12mo. 313 pp. Cloth, $1.50. 

" This book is a compact presentation of those facts and principles which require to be taken 
into account in estimating human responsibility— not legal responsibility merely, but responsi- 
bility for conduct in the family, the school, and all phases of social relation in which obligation 
enters as an element. The work is new in plan, and was written to supply a wide-felt want 
which has not hitherto been met. 11 — The Popular Science Monthly. 

2 



18 D. Appleton <# Co. 'a Medical Publications.* 

ROBERTSON. 

IVI lnd ! A Quarterly Review of Psychology and Philosophy. 
Price, $4.00 per Year. 

This new and important periodical, devoted to the science of mind in its mod- 
ern aspects, has a broad claim upon the thoughtful classes of the community — 
teachers, professors, physicians, lawyers, clergymen, students, and all interested 
in the general advance of ideas. 

" Mind " is edited by Prof. Croom Robertson, of University College, London, 
assisted by Prof. Bain and a large number of the ablest psychologists of England ; 
and it will be an organ for the publication of original researches, and a critical 
record of the progress made in psychology and philosophy in England, on the 
Continent, and in the United States. Mental phenomena will be taken up on the 
physiological side, as well as on the side of consciousness, as displayed in the 
inferior races of mankind, and in the lower animals ; in its abnormal phases, as 
insanity and idiocy ; in its relation to language, and in its bearing upon the sub- 
ject of education. It will also give careful reports of the state and progress of 
psychological study in the universities of different countries. 

MARKOE. 

A Treatise on Diseases of the Bones. 

By THOMAS M. MARKOE, M.D., 

Professor of Surgery in the College of Physicians and Surgeons, New York, etc. 

WITH NUMEEOUS ILLU8TE ATION3. 

1 vol., 8vo. Cloth, $4.50. 

This valuable work is a treatise on Diseases of the Bones, embracing their 
structural changes as affected by disease, their clinical history and treatment, in- 
cluding also an account of the various tumors which grow in or upon them. None 
of the injuries of bone are included in its scope, and no joint diseases, excepting 
where the condition of the bone is a prime factor in the problem of disease. As 
the work of an eminent surgeon of large and varied experience, it may be re- 
garded as the best on the subject, and a valuable contribution to medical litera- 
ture. 

" The book which I now offer to my professional brethren contains the substance of the lec- 
tures which I have delivered during the past twelve years at the college. ... I have followed 
the leadings of my own studies and observations, dwelling more on those branches where I had 
seen and studied most, and perhaps too much neglecting others where my own experience was 
more barren, and therefore to me less interesting. I have endeavored, however, to make up the 
deficiencies of my own knowledge by the free use of the materials scattered so richly through 
our periodical literature, which scattered leaves it is the right and the duty of the systematic 
writer to collect and to embody in any account he may offer of the state of a science at any given 
period. 11 — Extract from Author's Preface. 



D. Appleton db Co.'s Medical Publications. 19 

MEYER 
Electricity in its Relations to Practical 

Medicine, 

By Dk. MORITZ MEYER, 

Eoyal Counsellor of Health, etc. 

Translated from the Third German Edition, with Notes and Additions, 
A New and Revised Edition, 

By WILLIAM A. HAMMOND, M. D., 

Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, in the Bellevue 
Hospital Medical College ; Vice-President of the Academy of Mental Sciences, National 
Institute of Letters, Arts, and Sciences ; late Surgeon-General U. S. A., etc. 

1 vol., 8vo. 497 pp. Cloth, $4.50. 
"It is the duty of every physician to study the action of electricity, 
to become acquainted with its value in therapeutics, and to follow the 
improvements that are being made in the apparatus for its application in 
medicine, that he may be able to choose the one best adapted to the 
treatment of individual cases, and to test a remedy fairly and without 
prejudice, which already, especially in nervous diseases, has been used 
with the best results, and which promises to yield an abundant harvest 
in a still broader domain." — From Author's Preface. 

SPECIMEN OF ILLUSTBATIONS. 




Saxton-Ettinghausen Apparatus. 

** Those who do not read German are under great obligations to William A, 
Hammond, who has given them not only an excellent translation of a most ex- 
cellent work, but has given us much valuable information and many suggestions 
from his own personal experience." — Medical Record. 

" Dr. Moritz Meyer, of Berlin, has been for more than twenty years a laborious 
and conscientious student of the application of electricity to practical medicine, 
and the results of his labors are given in this volume. Dr. Hammond, in making 
a translation of the third German edition, has done a real service to the profession 
of this country and of Great Britain. Plainly and concisely written, and simply 
and clearly arranged, it contains just what the physician wants to know on the 
subject." — K Y. Medical Journal 

" It is destined to fill a want long felt by physicians in this country." — Journal 
of Obstetrics. 



20 D. Appleton & Co.h Medical Publications. 

NIEMEYER 
A Text-Book of Practical Medicine. 

With Particular Reference to Physiology and Patho- 
logical Anatomy. 

By the late Dr. FELIX VON NIEMEYER, 

Professor of Pathology and Therapeutics ; Director of the Medical Clinic of the University of 

Tubingen. 

Translated from the Eig-hth German Edition, by special permission of 

tne Author, 

By GEORGE H. HUMPHREYS, M. D., 

lAts >ne of the Physicians to the Bureau of Medical and Surgical Relief at Bellevue Hospital for 
the Out-door Poor ; Fellow of the New York Academy of Medicine, etc., 

and 
CHARLES E. HACKLEY, M. D., 

One of the Physicians to the New York TTospital; one of the Surgeons to the New York Ey© 
and Ear Infirmary ; Pellow of the New York Academy of Medicine, etc. 

Revised Edition. 2 vols., 8vo. 1,523 pp. Cloth, $9.00 ; Sheep, $11.00. 

The author undertakes, first, to give a picture of disease which shall 
be as lifelike and faithful to nature as possible, instead of being a mere 
theoretical scheme ; secondly, so to utilize the more recent advances 
of pathological anatomy, physiology, and physiological chemistry, as to 
furnish a clearer insight into the various processes of disease. 

The work has met with the most flattering reception and deserved 
success ; has been adopted as a text-book in many of the medical colleges 
both in this country and in Europe; and has received the very highest 
encomiums from the medical and secular press. 

" It is comprehensive and concise, and is characterized by clearness and 
originality." — Dublin Quarterly Journal of Medicine. 

" Its author is learned in medical literature ; he has arranged his materials 
with care and judgment, and has thought over them." — The Lancet. 

" As a full, systematic, and thoroughly practical guide for the student and 
physician, it is not excelled by any similar treatise in any language." — Appletons 7 
lour n al. 

" The author is an accomplished pathologist and practical physician ; he is not 
only capable of appreciating the new discoveries, which during the last ten years 
have been unusually numerous and important in scientific and practical medicine, 
but, by his clinical experience, he can put these new views to a practical test, and 
give judgment regarding them." — Edinburgh Medical Journal. 

" From its general excellence, we are disposed to think that it will soon take 
its place among the recognized text-books." — American Quarterly Journal of 
Medical Sciences. 

" The first inquiry in this country regarding a German book generally is, ' Is 
it a work of practical value ? " Without stopping to consider the justness of tho 
American idea of the ' practical,' we can unhesitatingly answer, ' It is ! ' " — New 
York Medical Journal. 

" The author has the power of sifting the tares from the wheat — a matter of 
the greatest importance in a text-book for students." — British Medical Journal. 

" Whatever exalted opinion our countrymen may have of the author's talents 
of observation and his practical good sense, his text-book will not disappoint 
them, while those who are so unfortunate as to know him only by name, have in 
Store a rich treat." — New York Medical Record, 



D. Applet on & CoSs Medical Publications. 21 

NEUMANN. 
Hand-Book of Skin Diseases. 

By Dr. ISIDOR NEUMANN, 
Lecturer on Skin Diseases in the Royal University of Vienna. 

Translated from, advanced sheets of the second edition, furnished by the 
Author; with Notes, 

By LUCIUS D. BULKLEY, A. M., M. D., 

'Surgeon to the Mew York Dispensary, Department of Venereal and Skin Diseases; Assist- 
ant to the Skin Clinic of the College of Physicians and Surgeons, New York; Mem- 
ber of the New York Dermatological Society, etc., etc. 

1 vol., 8vo. About 45D pages and 66 Woodcuts. Cloth, $4.00. 

Prof. Neumann ranks second only to Hebra, whose assistant he was for many y earn 
and his work may be considered as a fair exponent of the German practice of Dermatolo- 
gy. The book is abundantly illustrated with plates of the histology and pathology of the 
ekin. The translator has endeavored, by means of notes from French, English, and Ameri- 
can sources, to make the work valuable to the student as well as to the practitioner. 

"It is a work which I shall heartily recommend to my class of students at the Univer- 
sity of Pennsylvania, and one which I feel sure will do much toward enlightening the pro- 
fession on this subject.' 1 — Louis A. Duhring. 

" I know if to be a srood book, and I am sure that it is well translated; and it is inter- 
esting to find it illustrated by references to the views of co-laborers in the same field."— 
Erasmus IVilson. 

" So complete as to render it a most nseful book of reference."— T. McCall Anderson. 

"There certainly is no work extant which deals so thoroughly with the Pathological 
Anatomy of the Skin as does this hand-book." — V. Y. Medical Record. 

"The original notes by Dr. Bulkley are very practical, and are an important adjunct to 
the text. ... I anticipate for it a wide circulation."— Silas Durkee. Boston. 

"I have already twice expressed my favorable opinion of the book in print, and am 
.glad that it is given to the public at last."— James C. White, Boston. 

" More than two years ago we noticed Dr. Neumann's admirable work in its original 
shape ; and we are therefore absolved from the necessity of saying more than to repeat 
our strong recommendation of it to English readera." — Practitioner. 

NEFTEL. 

GalvanO-TherapeilticS. The Physiological and 

Therapeutical Action of the Galvanic Current upon 

the Acoustic, Optic, Sympathetic, and Pneumo gastric 

Nerves. 

By WILLIAM B. NEFTEL. 



1 vol., 12mo. 161 pp. Cloth, $1.50. 



This book has been republished at the request of several aural surgeons and 
other professional gentlemen, and is a valuable treatise on the subjects of wnich 
it treats. Its author, formerly visiting physician to the largest hospital of St. 
Petersburg, has had the very best facilities for investigation. 

" This little work shows, as far as it goes, full knowledge of what has been 
done on the subjects treated of, and the author's practical acquaintance with 
them." — New York Medical Journal. 

"Those who use electricity should get this work, and those who do not 
should peruse it to learn that there is one more therapeutical agent that they 
could and should possess." — The Medical Investigator. 



%% D. Appleton & Go's Medical Publications. 

NIGHTINGALE. 

N OteS OI1 N UrSlllg : What it is, and what it is not:. 

By FLORENCE NIGHTINGALE. 

1 vol., 12mo. 140 pp. Cloth, 75 cents. 

Every-day sanitary knowledge, or the knowledge of nursing, or, in other 
words, of how to put the constitution in such a state as that it will have no dis- 
ease or that it can recover from disease, takes a higher place. It is recognized 
as the knowledge which every one ought to have — distinct from medical knowl- 
edge, which only a profession can have. 

PAGET. 
Clinical Lectures and Essays. 

By Sir JAMES PAGET, Bart., 

P. E. S., D. C. L., Oxon., LL. D., Cantab. ; Sergeant-Surgeon Extraordinary to her Majesty the 
Queen ; Surgeon to H. E. H. the Prince of Wales ; Consulting Surgeon to St. Bartholomew's 
Hospital. 

Edited by HOWARD MARSH, 

Assistant Surgeon to St. Bartholomew's Hospital, and to the Hospital for Sick Children. 

1 vol., 8vo. Cloth. Price, $5.00. 

CONTENTS. 

The Various Risks of Operations — The Calamities op Surgery — Stam- 
mering with other Organs than those op Speech— Cases that Bone-Setters 
cure — Strangulated Hernia — Chronic Pyemia — Nervous Mimicry — Treat- 
ment op Cahbuncle — Sexual Hypochondriasis — Gouty Phlebitis — Residual 
Abscess — Dissection-Poisons — Quiet Necrosis — Senile Scrofula — Scarlet Fe- 
ver after Operations — Notes for the Study of some Constitutional Diseases 
— Notes — Index. 

PEBEIBA. 
Dr. Pereiras Elements of Materia 

Medica and Therapeutics. Abridged and adapted for 
the Use of Medical and Pharmaceutical Practitioners 
and Students, and comprising all the Medicines of the 
British Pharmacopoeia, with such others as are frequently 
ordered in Prescriptions, or required by the Physician. 

Edited by ROBERT BENTLEY and THEOPHILUS REDWOOD. 

New Edition. Brought down to 1872. 1 vol., Koyal 8vo. Cloth, S7.00; Sheep, 

$8.00. 



D. Appleton & Go's Medical Publications. 23 

PEASLEE. 

Ovarian Tumors; Their Pathology, Diagnosis, and 
Treatment, with Reference especially to Ovariotomy. 

By E. R. PEASLEE, M.D., 

Professor of Diseases of Women in Dartmouth College ; one of the Consulting Physicans to the 
New York State Woman's Hospital; formerly Professor of Obstetrics and Diseases of 
Women in the New York Medical College ; Corresponding Member of the Obstetrical 
Society of Berlin, etc. 

1 vol., 8vo. Illustrated with many Woodcuts, and a Steel Engraving of 3r. E. 
McDowell, the " Father of Ovariotomy." Price, Cloth, $5.00. 

This valuable work, embracing the results of many years of successful experience in the de- 
partment of which it treats, will prove most acceptable to the entire profession ; while the high 
standing of the author and his knowledge of the subject combine to make the book the best in 
the language. It is divided into two parts : the first treating of Ovarian Tumors, their anatomy, 
pathology, diagnosis, and treatment, except by extirpation; the second of Ovariotomy, its history 
and statistics, and of the operation. Fully illustrated, and abounding with information, the result 
of a prolonged study of the subject, the work should be in the kinds of every physician in the 
country. 

The following are some of the opinions of the press, at home and abroad, of this great work, 
which has been justly styled, by an eminent critic, " the most complete medical monograph on a 
practical subject ever produced in this country.' 1 '' 

"His opinions upon what others have advised are clearly set forth, and are as interesting and 
important as are the propositions he has himself to advance; while .there are a freshness, a vigor, 
an authority about his writing, which great practical knowledge alone can confer.'' — The Lancet. 

" Both Wells's and Peaslee's works will be received with the respect due to the great repu- 
tation and skill of their authors. Both exist not only as masters of their art, but as clear and 
graceful writers. In either work the student and practitioner will find the fruits of rich expe- 
rience, of earnest thought, and of steady, well-balanced judgment. As England is proud of 
Wells, so may America well be proud of Peaslee, and the great world of science may be proud 
of both." — British Medical Journal. 

" This is an excellent work, and does great credit to the industry, ability, science, and learning 
of Dr. Peaslee. Few works issue from the medical press so complete, so exhaustively learned, 
so imbued with a practical tone, without losing other substantial good qualities." — Edinburgh 
Medical Journal. 

" In closing our review of this work, we cannot avoid again expressing our appreciation of 
the thorough study, the careful and honest statements, and candid spirit, which characterize it. 
For the use of the student we should give the preference to Dr. Peaslee' 1 s work, not only from 
its completeness, but from its more methodical arrangement:' 1 — American Journal of Medical 
Sciences. 

■" Dr. Peaslee brings to the work a thoroughness of study, a familiarity with the whole field of 
histology, physiology, pathology, and practical gynaecology, not excelled, perhaps, by those of 
any man who ever performs the operation." — Medical Record. 

"We deem its careful perusal indispensable to all who would treat ovarian tumors with a 
good conscience." — Amencan Journal of Obstetrics. 

" It shows prodigal industry, and embodies within its five hundred and odd pages pretty 
much all that seems worth knowing on the subject of ovarian diseases." — Philadelphia Medical 
Times. 

" Great thoroughness is shown in Dr. Peaslee's treatment of all the details of this very ad- 
mirable work."— Boston Medical and Surgical Journal. 

"Indispensable to the American student of gynaecology." — Pacific Medical and Surgical 
Journal. 

XvCpOrtS. Bellevue and Charity Hospital Reports for 
1870, containing valuable contributions from 

Isaac E. Taylob, M. D., Austin Flint, M.D.. Lewis A. Satee, M.D., William A. Ham- 
mond, M. D., T. Gaillaed Thomas, M. D., Frank H. Hamilton, M. D., and others. 

1 vol., 8vo. Cloth, $4.00. 

"These institutions are the most important, as regards accommodations for patients and 
variety of cases treated, of any on this continent, and are surpassed by but few in the world. 
The gentlemen connected with them are acknowledged to be among the first in their profession, 
and the volume is an important addition to the professional literature of this country."— Psycho* 
logical Journal. 



24 D. Appleton & Co.'s Medical Publications. 

RICHARDSON. 
Diseases of Modern Life. 

By Dr. B. W. KICHARDSON, F. R. S. 
1 vol., 12mo. $2.00. 

Pakt the First.— PHENOMENA OF DISEASE, INCIDENTAL AND GENEKAL, ! 
Chap. I.— Natural Life to Natural Death. Euthanasia. 

II. — Phenomena of Disease, Classification and Distribution. 
III. — Disease Antecedent to Birth. 
I\ r . — External 'Origins and Causes of Disease. 
V.— Phenomena of Disease, from Causes External and Uncontrollable. 
VI. — Phenomena of Disease, from Causes External and Communicable. 
VII.— Phenomena of Disease, incidental to Old Age and Natural Decay. 

Pakt the Second.— PHENOMENA OF DISEASE, INDUCED AND SPECIAL. 

Chap. L— Definition and Classification of Induced Diseases. 

" II. — Disease from Worry and Mental Strain (Broken Heart). 

" III.— Disease from Worry and Mental Strain, continued (Paralysis). 

" IV. — Disease from Physical Strain. 

" V.— Disease from Combined Physical and Mental Strain. 

" VI.— Disease from the Influence of the Passions. 

" VII.— Disease from Alcohol. Physiological Proem. 

" VIII. — Phenomena of Disease from Alcohol. The Functional Type. 

" IX.— Organic Disease from Alcohol. 

" X.— Disease from Tobacco. Physiological Phenomena. 

" XL— Disease from Tobacco, continued (of the Heart and Lungs). 

" XII. — Disease from Tobacco, continued (of the Brain and Nervous System). 

" XIIL— Disease from the Use of Narcotics (from Opium, Chloral, and Absinthe). 

" XIV. — Disease from Misuse of Foods. 

" XV. — Disease incident to some Occupations. 

" XVI.— Dkease from Late Hours and Deficient Sleep. 

" XVII. — Disease from Imperfect Supply of Air. 
" XVI II.— Disease from Imitation and Moral Contagion. 

Part the Third.— SUMMARY OF PRACTICAL APPLICATIONS. 

STEINER 
Compendium of Children's Diseases. 

A Hand-hook for Practitioners and Students. 
By Dr. JOHAOTST STEIKER, 

Professor of the Diseases of Children in the University of Prague, and Physician to the Francis- 
Joseph Hospital for Sick Children. 

Translated from the Second German Edition by Lawson Tait, F. B. C. S., 

Surgeon to the Birmingham Hospital for Women ; Consulting Surgeon to the West Bromwich 
Hospital; Lecturer on Physiology at the Midland Institute. 

1 vol., 8vo. Cloth, $3.50. 

TRANSLATOR'S PREFACE. 

Dr. Steiner's book has met with such marked success in Germany that a second edition has 
already appeared, a circumstance which has delayed the appearance of its English form, in order 
that I might be able to give his additions and corrections. 

In Germany the use of the metric system has not yet entirely superseded the local measures; 
but it is rapidly doing so, as in England. I have, therefore, rendered all thermometric observa- 
tions in the Centigrade scale, and all measurements in centi- and millimetres. 

I have added as an Appendix the " Rules for Management of Infants" which have been issued 
by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an 
example by freely distributing these rules among the poor for which they cannot be sufficiently 
commended, and which it would be wise for other sick children's hospitals to follow. 

I have also added a few notes, chiefly, of course, relating to the surgical ailments of children. 

Birmingham, October, 1874. LAWSON TAIT. 



D. Appleton <fc CoSs Medical Publications. 25 

STROUD. 
The Physical Cause of the Death of 

Christ, and its Relations to the Principles and Practice 

of Christianity. 

By WILLIAM STROUD, M. D. 
With, a Letter on the Subject, by Sir James Y. Simpson, Bart., M. D. 
1 vol., 12mo. 422 pp. Cloth, $2.00. 
This important and remarkable book is, in its own place, a masterpiece, and will be considered 
.as a standard work for many years to come. 

"The principal point insisted on is, that the death of Christ was caused by rupture or lacera- 
tion of the heart. Sir James Y. Simpson, who had read the author's treatise and various com- 
ments on it, expressed himself very positively in favor of the views maintained by Dr. Stroud." 
— Psycholoyicat Journal. 

SIMPSON. 

The Posthumous Works of Sir James 

Young Simpson, Part., M. D. In Three Volumes. 

Volume I. — Selected Obstetrical and Gynaecological Works of Sir James Y. Simpson, 
Bart., M. D., D. C. L., late Professor of Midwifery in the University of Edinburgh. Contain- 
ing the substance of his Lectures on Midwifery. Edited by J. Watt Black. A. M.. M. D., 
Member of the Koyal College of Physicians. London ; Physician- Accoucheur to Charing 
Cross Hospital, London; and Lecturer on Midwifery and Diseases of Women and Children 
in the Hospital School of Medicine. 

1 vol., 8vo. 852 pp. Cloth, S3. 00. 
This volume contains all the more important contributions of Sir James Y. Simpson to the 
atudy of obstetrics and diseases of Women, with the exception of his clinical lectures on the latter 
subject, which will shortly appear in a separate volume. This first volume contains many of the 
papers reprinted from his Obstetric Memoirs and Contributions, and also his Lecture Notes, now 
published for the first time, containing the substance of the practical part of his course of mid- 
wifery. It is a volume of great interest to the profession, and a fitting memorial of its renowned 
and talented author. 

" To many of our readers, doubtless, the chief of the papers it contains are familiar. To 
others, although probably they may be aware that Sir James Simpson has written on the sub- 
jects, the papers themselves will be new and fresh. To the first class we would recommend this 
edition of Sir James Simpson's works, as a valuable volume of reference; to the latter, as a collec- 
tion of the works of a great master and improver of his art, the study of which cannot fail to make 
them better prepared to meet and overcome its difficulties.'' 1 — Medical Times and Gazette. 

Volume II. — Anaesthesia, Hi spitalism, etc. Edited by Sir Walter Simpson, Bart. 
1 vol., 8vo. 560 pp. Cloth, S3.00. 

" We say of this, as of the first volume, that it should find a place on the table of every prac- 
titioner ; for, though it is patchwork, each piece may be picked out and studied with pleasure and 
profit." — The Lancet (London). 

Volume III. — The Diseases of Women. Edited by Alex. Simpson, M. D., Professor 
of Midwifery in the University of Edinburgh. 

1 vol., 8vo. Cloth, $3.00. 

One of the best works on the subject extant. Of inestimable value to every physician. 

SWETT. 
A Treatise on the Diseases of the Chest. 

Being a Course of Lectures delivered at the JS r ew York 

Hospital. 

By JOHN A. SWETT, M. D., 

Professor of the Institutes and Practice of Medicine in the New York University ; Physician to 
the New York Hospital ; Member of the New York Pathological Society. 

1 vol., 8vo. 587 pp. $3.50. 

Embodied in this volume of lectures is the experience of ten years in hospital and private 
practice. 



26 D. Appleton <fc CoSs Medical Publications, 

SAYBE. 
A Practical Manual on the Treatment 

of Club-Mot. 

By LEWIS A. SAYRE, M. D., 

Professor of Orthopedic Surgery in Bellevue Hospital Medical College; Surgeon to Bellevue and 
Charity Hospitals, etc. 

1 vol , 12mo. New and Enlarged Edition. Cloth, $1.00. 

" The object of this work is to convey, in as concise a manner as possible, all the practical in- 
formation and instruction necessary to enable the general practitioner to apply that plan of treat- 
ment which has been so successful in my own hands. 1 '' — Preface. 

"The book will very well satisfy the wants of the majority of general practitioners, for whose 
use, as stated, it is intended."— New York Medical Journal. 

SMITH. 

On Foods. 

Br EDWARD SMITH, M. D., LL. B., F. R. S., 

Fellow of the Eoyal College of Physicians of London, etc., etc. 

1 vol., 12mo. Cloth. Price, $1.75. 

" Since the issue of the author's work on " Practical Dietary,' 1 he has felt the want of another, 
which would embrace all the generally-known and less-known foods, and contain the latest scien- 
tific knowledge respecting them. The present volume is intended to meet this want, and will be 
found useful for reference, to both scientific and general readers. The author extends the ordi- 
nary view of foods, and includes water and air, since they are important both in their food and 
sanitary aspects. 

SCHROEDER 
A Manual of Midwifery, including the Pa- 

thology of Pregnancy and the Puerperal State, 

By Dr. KARL SCHROEDER, 

Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen. 

TRANSLATED FEOM THE THIRD GERMAN EDITION 

By CHARLES H. CARTER, B. A., M. D., B. S. London, 

Member of the Eoyal College of Physicians, London, and Physician Accoucheur to St. George's* 
Hanover Square, Dispensary. 

With Twenty-six Engravings on Wood. 1 vol., 8vo. Cloth. 

" The translator feels that no apology is needed in offering to the profession a translation of 
Schroeder's Manual of Midwifery. The work is well known in Germany and extensively used as- 
a text-book ; it has already reached a third edition within the short space of two years, and it i& 
hoped that the present translation will meet the want, long felt in this country, of a manual of 
midwifery embracing the latest scientific researches on the subject. 

TILT. 

A Hand-Book of Uterine Therapeu- 

tics and of Pis eases of Women. 

By EDWARD JOHN TILT, M. D., 

Member of the Eoyal College of Physicians ; Consulting Physician to the Farringdon General 
Dispensary; Fellow of the Eoyal Medical and Chirurgical Society, and of several British and. 
foreign societies. 

1 vol., 8vo. 345 pp. Cloth, $3.50. 

Second American edition, thoroughly revised and amended. 

" In giving the result of his labors to the profession the author has done a great work. Our 
readers will find its pages very interesting, and, at the end of their task, will feel grateful to the 
author for many very valuable suggestions as to the treatment of uterine diseases." — The Lancet. 

"Dr. Tilt's ' Hand-Book of Uterine Therapeutics 1 supplies a want which has often been felt. 
. . It may, therefore, be read not only with pleasure and instruction, but will also be found 
very useful as a book of reference. 11 — The Medical Mirror. 

" Second to none on the therapeutics of uterine disease. 11 — Journal of Obstetrics. 



D. Appleton & CoSs Medical Publications. 27 

VAN BUREN AND KEYES 
A Practical Treatise on the Surgical 

Diseases of the Genito- Urinary Organs, including Syphi- 
lis. Designed as a Manual for Students and Practition- 
ers. With Engravings and Cases. 

By W. H. VAN BUREN, A. M., M. D., 

Professor of Principles of Surgery, with Diseases of the Genito-Urinary System and Clinical 
Surgery, in Bellevue Hospital Medical College ; Consulting Surgeon to the New York Hos- 
pital, the Charity Hospital, etc. ; and 

E. L. KEYES, A. M., M. D., 

Professor of Dermatology in Bellevue Hospital Medical College ; Surgeon to the Charity Hos^ 
pital, Yenereal Diseases ; Consulting Dermatologist to the Bureau of Out-Door Relief, Belle- 
vue Hospital, etc. 

1 vol., 8vo. Cloth, $5.00 ; Sheep, $6.00. 

This work is really a compendium of, and a book of reference to, all modern 
works treating in any way of the surgical diseases of the genito-urinary organs. At 
the same time, no other single hook contains so large an array of original facts con- 
cerning the class of diseases with which it deals. These facts are largely drawn, 
from the extensive and varied experience of the authors. 

Many important branches of geni to-urinary diseases, as the cutaneous maladies 
of the penis and scrotum, receive a thorough and exhaustive treatment that the pro- 
fessional reader will search for elsewhere in vain. 

The work is elegantly and profusely illustrated, and enriched by fifty-five 
original cases, setting forth obscure and difficult points in diagnosis and treatment. 

" The first part is devoted to the Surgical Diseases of the Genito-Urinary Organs ; and part 
second treats of Chancroid and Syphilis. The authors ' appear to have succeeded admirably in 
giving to the world an exhaustive and reliable treatise on this important class of diseases.' " — 
Northwestern Medical and Surgical Journal. 

" It is a most complete digest of what has long been known, and of what has been more re- 
cently discovered, in the field of syphilitic and genito-urinary disorders. It is perhaps not an 
exaggeration to say that no single work upon the same subject has yet appeared, in this or any 
foreign language, which is superior to it"— Chicago Medical Examiner. 

" The commanding reputation of Dr. Van Buren in this specialty and of the great school and 
hospital from which he has drawn his clinical materials, together with the general interest which 
attaches to the subject-matter itself, will, we trust, lead very many of those for whom it is our 
office to cater, to possess themselves at once of the volume and form their own opinions of its 
merit."— Atlanta Medical and Surgical Journal. 

Lectures upon Diseases of the Rectum. 

Delivered^ at the Bellevue Hospital Medical College. 
Session o/1869-'70. 

By W. H. VAN BUREN, M. D., 

1 vol., 12mo. 164 pages. Cloth, $1.50. 

" It seems hardly necessary to more than mention the name of the author of this admirable 
little volume in order to insure the character of his book. No one in this country has enjoyed 
greater advantages, and had a more extensive field of observation in this specialty, than Dr. 
Yan Buren, and no one has paid the same amount of attention to the subject. . . . Here is the 
experience of years summed up and given to the professional world in a plain and practical man- 
ner. 1 '' — Psychological Journal, 



:28 J9. Applet on & CoSs Medical Publications, 

VOGKEL. 

A Practical Treatise on the Diseases 

of Children, Second American from the Fourth 
German JEdition. Illustrated by Six Lithographic 
Plates, 

By ALFRED YOGEL, M. D., 

Professor of Clinical Medicine in the University of Dorpat, Busais. 
TEANSLATED AND EDITED BY 

H. RAPHAEL, M. D., 

ILste House Surgeon to Bellevuo Hospital ; Physician to the Eastern Dispensary for 4he Diseases 
of Children, etc., etc. 

1 vol., 8vo. 611 pp. Cloth, $4.50. 

The work is well up to the present state of pathological knowledge ; 
complete without unnecessary prolixity; its symptomatology accurate, 
evidently the result of careful observation of a competent and experi- 
enced clinical practitioner. The diagnosis and differential relations of 
diseases to each other are accurately described, and the therapeutics 
judicious and discriminating. All polypharmacy is discarded, and only 
the remedies which appeared useful to the author commended. 

It contains much that must gain for it the merited praise of all im- 
partial judges, and prove it to be an invaluable text-book for the stu- 
dent and practitioner, and a safe and useful guide in the difficult but all- 
important department of Psediatrica. 

" Rapidly passing to a fourth edition in Germany, and translated into three 
other languages, America now has the credit of presenting the first English ver- 
sion of a book which must take a prominent, if not the leading, position among 
works devoted to this class of disease." — N. Y. Medical Journal. 

" The profession of this country are under many obligations to Dr. Raphael 
for bringing, as he has dona, this truly valuable work to their notice." — Medical 
Record. 

" The translator has been more than ordinarily successful, and his labors 
have resulted in what, in every sense, is a valuable contribution to medica* 
science." — Psychological Journal. 

"We do not know of a compact text-book on the diseases of children more 
complete, more comprehensive, more replete with practical remarks and scientific 
facts, more in keeping with the development of modern medicine, and more 
worthy of the attention of the profession, than that which has been the subject 
of our remarks." — Journal of Obstetrics. 



D. Appleton & CoSs Medical Publications. 29 

WALTON. 
The Mineral Springs of the United 

States and Canada, with Analyses and Notes on the 
Prominent Spas of Europe, and a List of Sea-side 
JResorts. An enlarged and revised edition. 

By GEORGE E. WALTON, K D., 

Lecturer on Materia Medica in the Miami Medical College, Cincinnati. 

Second Edition, revised and enlarged. 1 vol., 12mo. 390 pp., with. Maps. S2.00- 

The author has given the analyses of all the springs in this country and 
those of the principal European spas, reduced to a uniform standard of 
one wine-pint, so that they may readily be compared. He has arranged 
the springs of America and Europe in seven distinct classes, and de- 
scribed the diseases to which mineral waters are adapted, with refer- 
ences to the class of waters applicable to the treatment, and the pecul- 
iar characteristics of each spring as near as known are given — also, the 
location, mode of access, and post-office address of every spring are men- 
tioned, In addition, he has described the various kinds of baths and 
the appropriate use of them in the treatment of disease. 

EXTRACTS FROM OPINIONS OF THE PRESS. 

"... Precise and comprehensive, presenting not only reliable analyses of 
the waters, but their therapeutic value, so that physicians can hereafter advise 
their use as intelligently and beneficially as they can other valuable alterative 
agents." — Sanitarian. 

"... Will tend to enlighten both the profession and the people on this 
question." — N. Y. Medical Journal, 

"... Contains in brief space a vast amount of important and interesting 
matter, well arranged and well presented. Nearly every physician needs just 
such a volume " — Riclunond and Louisville Medical Journal. 

"... Fills this necessity in a scientific and pleasing manner, and can be read 
with advantage by the physician as well as layman." — American Jour, of Obstetrics. 

Uottebsity op VntorsfiA, June 9, 1873. 

Gentlemen : I have received by mail a copy of Dr. Walton's work on the 
Mineral Springs of the United States and Canada. Be pleased to accept my 
thanks for a work which I have been eagerly looking for ever since I had the 
pleasure of meeting the author in the summer of 1871. He satisfied me that 
he was well qualified to write a reliable work on this subject, and I doubt not 
he has met my expectations. Such a work was greatly needed, and, if offered 
for sale at the principal mineral springs of the country, will, I believe, com. 
mand a ready sale. Yery respectfully yours, 

J. L. Cabell, M. D. 



30 D. Applet on & CoSs Medical Publications. 

WELLS. 

Diseases of the Ovaries ; Their Diagnosis 

and Treatment. 

By T. SPENCER WELLS, 

Fellow and Member of Council of the Koyal College of Surgeons of England; Honorary Fellow 
of the King and Queen's College of "Physicians in Ireland; Surgeon in Ordinary to the 
Queen's Household; Surgeon to the Samaritan Hospital for Women; Member of the Im- 
perial Society of Surgery of Paris, of the Medical Society of Paris, and of the Medical Soci- 
ety of Sweden ; Honorary Member of the Royal Society of Medical and Natural Science 
of Brussels, and of the Medical Societies of Pesth and Helsingfors ; Honorary Fellow of 
the Obstetrical Societies of Berlin and Leipzig. 

1 vol., 8vo. 478 pp. Illustrated. Cloth, Price, $4.50. 

In 1865 the author issued a volume containing reports of one hundred and 
fourteen cases of Ovariotomy, which was little more than a simple record of 
facts. The book was soon out of print, and, though repeatedly asked for a 
new edition, the author was unable to do more than prepare papers for the 
Royal Medical and Chirurgical Society, as series after series of a hundred cases 
accumulated. On the completion of five hundred cases he embodied the results 
in the present volume, an entirely new work, for the student and practitioner, 
and trusts it may prove acceptable to them and useful to suffering women. 

" Arrangements have been made for the publication of this volume in Lon- 
don on the day of its publication in New York." French and German transla- 
tions are already in press. 

WAGNER 

A Hand - book of Chemical Tech- 

nology. 

By RUDOLPH WAGNER, Ph. D., 

Professor of Chemical Technology at the University of Wurtzburg. 

Translated and edited, from the eighth German edition, with exteutiive 

additions, 

By WILLIAM CROOKES, F. R. S. 

With 336 Illustrations. 1 vol., 8vo. 761 pages. Cloth, $5.00. 

Under the head of Metallurgic Chemistry, the latest methods of preparing Iron, Cobalt, 
Nickel, Copper, Copper Salts, Lead and Tin. and their Salts, Bismuth, Zinc, Zinc Salts, Cad- 
mium, Antimony, Arsenic, Mercury, Platinum, Silver, Gold, Manganates. Aluminum, and 
Magnesium, are described. The various applications of the Voltaic Current to Electro-Metal- 
lurgy follow under this division. The preparation of Potash and Soda Salts, the manufacture 
of Sulphuric Acid, and the recovery of Sulphur from Soda Waste, of course occupy prominent 
places in the consideration of chemical manufactures. It is difficult to over-estimate the mer- 
cantile value of Mond's process, as well as the many new and important applications of Bisul- 
phide of Carbon. The manufacture of Soap will be found to include much detail. The Tech- 
nology of Glass, Stone-ware, Limes, and Mortars, will present much of interest to the Builder 
and Engineer. The Technology of Vegetable Fibres has been considered to include tbe prep- 
aration of Flax. Hemp. Cotton, as well as Paper-making; while the applications of Vegetable 
Products will be found to include Sugar-boiling. Wine and Beer Brewing, the Distillation of 
Spirits, the Baking of Bread, the Preparation of Vinegar, the Preservation of Wood, etc. 

Dr. Wagner gives much information in reference to the production of Potash from Sugar 
residues. The use of Baryta Salts is also fully described, as well as the preparation of Sugar 
from Beet-roots. Tanning, the Preservation "of Meat. Milk, etc., the Preparation of Phospho- 
rus and Animal Charcoal, are considered as belonging to the Technology of Animal Products. 
The Preparation of Materials for Dyeing has necessarily required much space ; while the flnaJ 
sections of the book have been devoted to the Technology of Heating and Illumination. 



NEW MEDICAL WORKS IN PRESS. 



BARTHOLOW'S TREATISE ON THERAPEUTICS. 

CONTRIBUTIONS TO REPARATIVE SURGERY, showing its Application to the 
Treatment of Deformities, produced by Destructive Disease or Injury ; Con- 
genital Defects from Arrest or Excess of Development; and Cicatricial Con- 
tractions following Burns. Illustrated by Thirty Cases and fine Engravings. 
By Gubdon Buck, M. D. 

ACNE ; its Pathology, Etiology, Prognosis, and Treatment. By L. Duncan Bulk- 
ley, A. M., M. D., New York Hospital. A monograph of about seventy pages, 
illustrated, founded on an analysis of two hundred cases of various forms of 
Acne. 

LECTURES ON ORTHOPEDIC SURCJERY AND DISEASES OF THE JOINTS, 

delivered at Bellevue Hospital Medical College during the Winter Session of 
1874^1875, by Lewis A. Sayre, M. D., Professor of Orthopedic Surgery, Frac- 
tures and Dislocations, and Clinical Surgery, in Bellevue Hospital Medical Col- 
lege ; Surgeon to Bellevue Hospital ; Consulting Surgeon to Charity Hospital ; 
Consulting Surgeon to St. Elizabeth's Hospital ; Consulting Surgeon to North- 
western Dispensary ; Member of the American Medical Association ; Perma- 
nent Member of the New York State Medical Society ; Eellow of the New York 
Academy of Medicine ; Member of the New York County Medical Society, of 
the New York Pathological Society, of the Society of Neurology, of the Medico- 
Legal Society ; Honorary Member of the New Brunswick Medical Society ; 
Honorary Member of the Medical Society of Norway ; Knight of the Order of 
Wasa, by His Majesty the King of Sweden, etc., etc. Elustrated by Numerous 
Wood-Engravings. 1 vol., Svo. Cloth, $5.00; Sheep, $6.00. 

The publishers take pleasure in announcing that the above work is now passing 
through the press, and will be ready by the 20th of April, 1876. It is being pub- 
lished at the request of medical gentlemen of the highest standing, in different sec- 
tions of. our country, as well as many abroad, who are anxious to have Dr. Sayre's 
peculiar views and extended experience in this specialty given to the profession in 
a plain and practical manner. The book contains the substance of his course of lec- 
tures delivered at Bellevue Hospital Medical College, as well as many important 
cases from his note-book, and from the hospital records. He has also added a num- 
ber of cases before presented by him to the profession in medical journals, or at the 
different medical societies, which are considered worthy of permanent record. 

The work is enriched by beautiful and excellent illustrations, engraved from 
original drawings and photographs prepared expressly therefor. The author having 
enjoyed exceptional opportunities for the study and treatment of these diseases, the 
results of his labors cannot fail to be of inestimable value to every student and 
practitioner, and of service to suffering humanity. 



Students desiring early copies will please send their orders direct to the pub- 
lishers, 

D. APPLETON & CO., Publishers, 

549 & 55 1 Broadway, New York, 



THE NEW YORK MEDICAL JOURNAL 

JAMES B. HUNTER, M. D., Editor. 
Published Monthly. Volumes begin in January and July, 



"Among the numerous records of Medicine and the collateral sciences published in America* 
the above Journal occupies a high position, and deservedly so." — The Lancet {London). 

"One (.f the best medical journals, by-the-by, published on the American Continent." — Lon- 
don Medical 7 imes and Gazette. 

4k A very high-class journal."— London Medical Mirror. 

"The editor and the contributors rank among our most distinguished medical men, and each 
number contains matter that does honor to American medical literature."— Bos ton Journal of 
Chemistry. 

"Full of valuable original papers, abounding in scientific ability."— Chicago Medical Times 

"■\Ve know no other periodical that we would rather present as a specimen of American skiL 
and intelligence than tbe New York Medical .Journal."' — Franklin Repository. 

"The New York Medical Journal, edited by Dr. James B. Hunter, is one of the sterling 
periodicals of this country. The present editor has greatly improved the work, and evinces a 
marked aptitude for the responsible duties so well discharged. The contents of this journal are 
always interesting and instructive; its original matter is often classic in value, and the selected 
articles are excellent exponents of the progress and truth of medical science." — Richmond and 
Louisville Medical Journal. 

Terms, $4.00 per Annum; or 40 Cents per Number. ' 

o— © _» 

THE POPULAR SCIENCE MONTHLY. 

Conducted oy Prof. E. L. YOUMAJYS. 

Each Number contains 128 pages, with numerous Descriptive and 
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Published Monthly. Volumes begin in May and November. 

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The Pop— as Science Montttly was started to promote the diffusion of valuable scientific 
knowledge, in a readable and attractive form, among all classes of the community, and has thus 
far met a' want supplied by no other periodical in the United States. 

The great feature of the magazine is, that its contents are not what science was ten or more 
years since, but what it is to-day, fresh from the study, the laboratory, and the experiment: 
clothed in the language of the authors, inventors, and scientists themselves, which comprise the 
leading minds of England. France. Germany, and the United States. Among popular articles, 
covering the whole range of Natural Science, we have the latest thoughts and words of Her- 
bert Spencer, and Professors Huxley, TyndalL and K. A. I'mctor. Since the start, it has proved 
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believed that science could not be made any thing but dry study, are disappointed. 

The press all over the land is warmly commending it. We subjoin a few encomiums from 
those recently given: 

11 A journal which promises to be of eminent value to the cause of popular education in this 
countrv." — '\ew York Tribune. 

" It' is, beyond comparison, the best attempt at journalism of the kind ever made in this coun- 
try." — Home Journal. 

"The initial number is admirably constituted."— Ereninq Mail. 

" In our opinion, the right idea has been happily hit in the plan of this new monthly." — Buffalo 
Courier. 

"Just the publication needed at the present day." — Montreal Gazette. 



Payment, in all cases, must be made in advance, 

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